This headline above is the one I’ve been waiting for. But the one this past week in the NY Times was more in line with the usual narrative: “As Population Ages, Where Are the Geriatricians?”
Now, I’m always glad to see geriatrics in the news, because this helps people know/remember that geriatrics exists.
But this article was like many: heart-warming stories of how we take better care of frail older adults, gloomy statistics on how few geriatricians we have, the requisite comments about how few doctors are signing up to train as geriatricians and how it might be because the pay is less than other doctors.
There was also the usual conflating of geriatrics with geriatricians — there’s mention of the efforts to train other clinicians in geriatrics but it’s brief. Overwhelmingly, the message seems to be that you need one of these special docs to be your PCP (or your mom’s PCP) if you want better health while aging. But these docs are scarce and getting scarcer, so disaster looms for an aging population.
My concern: this feels like a discouraging message.
Given the very definite shortage of geriatricians, I want to see headlines how we might improve healthcare for older adults even though we are short on geriatricians.
In other words, how can we leverage what we know and do in geriatrics?
Ideas on Making Geriatrics Care More Widely Available
What we need are some well-researched magazine articles on the topic, but in the meantime, here are a few ideas I’ve been thinking about:
“Virtual Geriatrics” for information and consultations
Did you know that a Virtual Hospice service has existed in Canada since 2004? Here is an excerpt from their about page:
The Canadian Virtual Hospice provides support and personalized information about palliative and end-of-life care to patients, family members, health care providers, researchers and educators.
The Story of the Canadian Virtual Hospice
In 2001, a group of palliative care leaders gathered to consider whether a web-based platform could address some of the gaps in palliative care in Canada. They recognized that Canadians need a reputable source for finding information and support, whenever they need it, wherever they live.
They envisioned the creation of a “virtual hospice.” A place where:
- People without ready access to palliative care specialists could ask questions of a clinical team specialized in palliative care.
- Families could read articles about managing symptoms, accessing financial benefits, and other topics to help them navigate the health care system and communicate with their local health care providers.
- Health care professionals could easily access tools to better care for and communicate with patients and families.
- Researchers could share their latest findings, allowing front-line health care providers to stay on top of important developments.
The Canadian Virtual Hospice went online in February 2004, with evidence-based information and an e-health pioneering feature called Ask a Professional. For the first time, Canadians had direct access to health specialists online. Since then, Canadians have found a safe place to sort through issues related to death and dying at the Virtual Hospice. The information and support they find here helps make sense in times of confusion, offers compassion in times of isolation, and reassurance in times of anxiety.
Neat, isn’t it?
If we have a shortage of geriatricians and an aging population, should we consider a virtual geriatrics consultation and support site? Could HealthinAging.org be expanded to serve this role? One could also envision consolidating information on one well-maintained site, and then offering people links to smaller sites for “Ask a Professional” or even virtual telehealth consultations.
A tech consideration for telehealth geriatric consultations: patients and families would really need to have a robust personal health record that easily sucks in information from other providers and easily shares information with a consultant. It needs to be easy for a geriatrician — or whatever clinician is going to offer extra input — to see clinical notes from other providers, labs, radiology results, etc. People ask me for advice often and even for something like “does my mom need to move to assisted-living?” more info on the health history is usually needed.
Encourage the public to expect and request geriatrics care from non-geriatrician clinicians.
The public knows that children should get healthcare that has been modified to suit their growing bodies. Even when an involved clinician is not a board-certified pediatrician or pediatric specialist, people expect other providers to somehow “pediatricize.” Hence family medicine doctors receive a lot of training in pediatrics; in fact all doctors receive training in pediatrics and are expected to apply some of that knowledge and approach when caring for a child.
Sadly, the public does not currently have similar expectations for geriatrics. This is partly because most people don’t understand what geriatrics is; they may not know it’s a medical specialty, or they may believe it is just for people who are extremely frail and in nursing homes.
But, it’s also because the media — and others — encourage people to believe that it’s only realistic to expect this care from geriatricians. Which is true right now, but it shouldn’t be.
If we help the public realize that their usual clinicians should be tapping into our existing geriatrics knowledge base on better health and healthcare for older adults, this might help stimulate ways to meet this demand.
Special hospital units for older adults should not be the exception. They should be present in every hospital. I suppose we could mandate them but it would also help if older adults were seeking them out and requesting them.
Likewise, it should probably be the default for older adults to get their primary care at “senior clinics,” like Oak Street Health and other practices that have been designed to optimize the primary care of older adults. But many older adults don’t realize that such practices exist.
Gently encourage practicing clinicians to get more geriatrics training and to be more open to geriatrics input.
When pediatric specialists first came on the scene, did the general practitioners pooh-pooh them, saying “Oh I take care of kids all the time, I know how to do this well”?
One unusual and interesting aspect of the recent NYT article is that it featured Dr. Elizabeth Eckstrom, an Oregon geriatrician who practiced as an internist for nine years before deciding to pursue additional training in geriatrics. Fellowship “opened her eyes. ‘I had no idea what I didn’t know,’ she said.”
Also interesting: the article noted that “Some primary care physicians argue that geriatricians are unnecessary, that most ailments among older adults are the same as those that hit the middle-aged population, such as diabetes, hypertension and heart disease. The difference, they say, is that older patients just have more of them.”
Obviously, those doctors are wrong. We don’t want geriatricians to be necessary, but delivering geriatrics — that suitably modified healthcare — IS necessary, to help older adults have the best health possible. (Furthermore, correctly done it should save money by reducing excess ED visits and hospitalizations.)
It seems likely that many primary care doctors do not realize that they are suboptimally managing their older patients. (“I didn’t know what I didn’t know) We will need to find diplomatic ways to change this widespread belief and encourage doctors to improve their ability to deliver geriatric care.
How Technology Can Help & Next Steps
How technology can help deliver more optimal care to older adults is the whole point of this blog. I also address this specifically in my short and practical ebook.
The way to support an aging population is to have as many people as possible learn to think more like geriatricians do. Most people will help aging parents or relatives. And all clinicians other than pediatricians and OBs are likely to provide care to older adults.
The public should be able to access information based on our expertise. Health apps and services should tap our knowledge base.
And tools for providers need to make it easier for them to implement a geriatrics approach. Right now we geriatricians encounter a lot of friction as we try to do what we know how to do, such as evaluate falls and memory problems, sort through medications, and address goals of care. How can we expect clinicians who don’t have our training and innate interest in older adults to attempt what we do? (That care coordination payment is not going to cut it.)
The population is aging and we are short on geriatricians. Let’s stop asking where they are, and instead find ways to ensure that all older adults can access geriatrics: healthcare that’s suitably modified to optimize their health and wellbeing.
Absolutely right! I’ll add another idea: IBM’s Watson and artificial intelligence initiatives by Google/Alphabet also hold the promise of easier access to diagnostic and treatment advice that’s specific to older patients. These tools can be tailored for physicians, nurses, families and other involved in caring for older patients.
These types of resources can also help older patients and their caregivers educate physicians and spur them to learn more about geriatric care.
There is certainly potential in such AI initiatives. I am wondering when we’ll see this tried under real-life conditions. It will likely take some iterating before it works reasonably well.
this may be good for people with various morbidities and respond differently to treatments, but it lacks the human interaction. e.g. In the book “being mortal” the author comments on the way the sensitive way the1 hospice nurse identifies his father’s particular desires.
I have an internist who is certified as a geriatrician, but I do not feel he understands my needs and desires. I have no serious health problems other than sarcopenia and he has not asked about this or suggested any solutions. I have to look for them on line..Some research has found that more omega 3 may help maintain muscle strength.
I also found that an internist was more sensitive to the needs of my children than a pediatrician I was using.
Another a major problem (which your blog tries to correct) is how to make elders aware of the various services that exist that will help them. Having worked for a Area Agency on Aging, and health systems agency, I am more aware of these services than the average elder. However, one of my granddaughters, who is a certified Nurse Practictioner, was hired by a PACE agency. I had been unaware of them until that time.
Recently I met a social worker in my apartment complex who had lost her job at a local PACE agency(Milwaukee) as they were under funded as they were not attracting sufficient clients. My granddaughter’s agency(Seattle) is also below their desired client level. I don’t know how to correct this problem. Any suggestions?
What lacks the human interaction?
Re low awareness about Area Agency on Aging and programs such as PACE, couldn’t agree more: we need for more people to be aware of these, to use them, and even to push for them to improve.
PACE (Program of All-Inclusive Care for the Elderly) is a fantastic program but it has not expanded widely even though it has been around for decades.
Some of the challenges in expanding PACE: The rules on PACE vary by state, but generally people have to be nursing-home eligible, they have to give up their usual doctors, they have to be in a catchment area, etc. Patients also usually have to have Medicaid, or be willing to pay a monthly fee. A new — or existing — PACE program has to not only take good care of its patients, but also has to be adept in recruiting patients and maintaining relationships with hospitals, residential facilities, etc…basically you have to be good at running the business side along with caring for the older adults and families.
I heard from a colleague working in PACE a few years ago that they wanted to find a way to expand and offer services to older adults who are not on Medicaid, or not yet nursing-home eligible. But I’m not sure where those efforts are at. Finding a way to offer a quality senior health service at a price that people and payors are willing to pay is a challenge.
As someone who has educated thousands of business leaders, clinicians, entrepreneurs and families about aging/health over the past 15 years, I am excited about the myriad ways that technology allows us to connect people, products and services to enhance the lives of older citizens. That said, one of the key voices missing in the mix has been gerontologists. Beyond publishing books and working with patients, both worthy initiatives, I am starting to see a few gerontologists, like yourself, recognize and seize the opportunity to educate a broader audience.
You ask a key question, “HOW do we disseminate the knowledge that geriatricians have so that older individuals are better supported?” There are many “distribution channels” to use business parlance. Some may want to embed knowledge in AI via Watson or equivalent. That’s great. Others may focus on Area Agencies on Aging and existing support services. Some may work through existing healthcare networks, like CareMore. Others will step into the world of entrepreneurship. Whatever the channel, we need MORE geriatricians sharing their knowledge beyond their medical practices. Here are a few examples…
One geriatrician has teamed up with an educator on an educational platform called Care Academy. http://www.careacademy.co/. They intend to train CNAs to better support their clients, an important need. There’s Dr. Bill Thomas traveling about the country with his “Changing Aging” roadshow, building awareness about the attributes of Elderhood, the stage in life that follows Adulthood. There’s a geriatrician at Beth Israel in Boston who is an expert in diabetes who is creating educational programs for internists who often do not have the depth of expertise to properly care for their patients. These are a good start, but more is needed.
You are among the new thought leaders, someone who can explain challenging topics clearly, without unnecessary medical jargon. I’ve already used your blog post about medication to educate families struggling with dementia and I encourage you to keep going. Create educational videos, develop a platform and sell your content to others. There are many ways to extend your reach and few, trust me, who speak with such clarity. The next time I’m in SF, let’s get together. And if you can get to Boston on April 21st, you may want to join me at Harvard’s Aging Market conference.
Keep well and in touch.
Janet, thank you so much for sharing those examples of geriatricians exploring new ways to expand access to our expertise.
And many thanks for encouraging me personally! I am, as you know, forging ahead creating content on BetterHealthWhileAging.net, although I’m not sure what there will be to sell as I would like for as many families as possible to benefit. It is tricky to figure out ways to provide the public with a needed service while still managing financial necessities…something I see come up repeatedly in the health tech and innovation space.
Please do let me know next time you are in SF!