DOCTOR’S WORD: Can Physicians Cope with a ‘Silver Tsunami?’

DOCTOR’S WORD: Can Physicians Cope with a ‘Silver Tsunami?’

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SAN DIEGO, Calif.--I attended a medical meeting once where the subject was “What is a Geriatrician?” There were probably 2,000 attentive doctors in the audience all waiting to hear what the main speaker, an internationally known physician, had to say about caring for the growing population of older patients.

When introduced he strode to the microphone, proclaimed, “A geriatrician is a doctor who stops drugs!” -- then went back to his seat and sat down.

Message delivered!

Then he returned to the podium for his presentation: The problem, he explained,  is poly-pharmacy where elders have too many physicians all prescribing drugs for them with no awareness of what the other doctors were writing for the same patient. Doctors trained in how to care for older adults learn that one of the first things to check when a patient becomes ill is whether the person is having an adverse drug reaction.

The meeting had an immediate impact. Here was an academic physician, who understood the problems of clinicians laboring in the trenches. He also had practical suggestions — like asking your patients to use just one drug store, so the pharmacist could see the total picture, and getting them to “brown bag it once a year,” so you could catch the anomalies, too. I once found three separate forms of Lasix or furosemide from three different doctors in a patient’s bag.

Eldercare Workforce Dangerously Undestaffed

But the world of academic medicine and gerontology is so removed from the experience of those working in the trenches that sometimes we barely learn from each other. For example, the Institute of Medicine (IOM) released a report in the spring of 2008, Retooling for an Aging America: Building the Health Care Workforce. It concluded America's eldercare workforce is dangerously understaffed — and unprepared to care for the rapidly growing number of older adults in the United States.

Since that 2008 IOM report --- and moving with all the glacial speed and majesty of government -- a coalition of 25 leading organizations formed a committee. The Eldercare Workforce Alliance did not meet until February 2009.

Although the Alliance took its time to come to conclusions its inferences were important (italics are mine):

“More than three-quarters of adults over age 65 suffer from at least one chronic medical condition that requires ongoing care and management. Older adults rely on health care services far more than other segments of the population. Additionally, this group will be the most diverse the nation has ever seen, with more education, increased longevity, widely dispersed families, and more racial and ethnic diversity, making their needs much different than previous generations.”

It used to be said: Two doctors, three opinions. But the 25 organizations “representing older adults and the eldercare workforce” had some very perceptive and unanimous findings, namely:

“As the population of older adults grows to comprise approximately 20 percent of the U.S. population, they will face a health care workforce that is too small and critically unprepared to meet their health needs. Recruitment and retention of geriatric specialists and health care aides needs to be boosted. More health care providers need to be trained in the basics of geriatric care and should be capable of caring for older patients. To attract and retain the geriatric specialists and aides that care for older Americans, we need to pay them higher salaries and wages.”

As I write this, Medicare payments to physicians have been cut again, showing the gap between well-meaning wishes and the reality of the marketplace.

And last week a company called IHS, “the leading source of information, insight and analytics in critical areas that shape today’s business landscape,” issued a press release stating the U.S. market for remote cardiac monitoring devices and services will increase by 25 percent from 2011 to 2016, when it will hit $867 million.

IHS says this increase suggests health providers will seek outpatient data, claiming it will reduce hospitalizations. Cynics might say all this will be an extra cost as medical care continues to become hi-tech and expensive.

“Bold Initiatives”?

So do we see society and the health care services preparing the “bold initiatives” the Eldercare Workforce Alliance felt were necessary? Not really.

The media have pointed out repeatedly since the first day of January 2011 that the Baby Boomers started to turn 65 and qualify for Medicare.

“One every eight seconds for a total of 2.8 million in 2011,” wrote USA Today’s Richard Wolf in his column of Dec. 30, 2010: “And projections show it will rise to 4.2 million by 2030.”

The same projections suggest a total of 78 million Boomers will enter the Medicare problem and, even allowing for deaths, Medicare will grow from 47 million today to 80 million in 2030.

Wolf quotes Gail Wilensky, former head of Medicare and Medicaid, as saying the nation will need more primary care doctors, nurses, gerontologists, nursing home workers and physical and occupational therapists — all of whom are in short supply.

The question arises: Can the American Health System, based as it is on specialized services for medically sophisticated patients whose preoccupation is crisis-oriented care, really handle this influx? Especially since now the Affordable Care Act (ACA) is throwing another 32 million previously uninsured patients into the mix?

A medical writer friend makes the point that “while ACA will help a lot of people, it really does very little to do what the U.S. needs to do — get control of all health care cost, not just futz around with government programs.”

My guess, as a physician, now age 80, who ended his professional career practicing geriatrics, would be that we are already stretched thin by current patient demands and might be ill prepared for this additional load.

“Medical Homes” Promising, But …

Sociologists wondered if the answer was the concept of the “the Patient Centered Medical Home Medical Home” — team-based coordinated health care delivery. The model goes back the late 1960s when pediatricians felt there should be a central source for information about children, especially those with special needs.

The idea has grown in the last few years into pilot programs, including under ACA, to address all primary care in America. It seems to work, but it is cumbersome and expensive, even though it could ultimately cut costs by validating preventive medicine.

As a British-trained physician (Edinburgh, Scotland, 1958), I came to the United States in 1960 looking forward to practicing fee-for-service medicine and have become disillusioned over the decades.

We handle chronic illness so badly in the States compared to, say, Europe or Canada. But I came to believe, strongly, that group health care would be, at least, one answer.

Eric Anderson lives in San Diego and is a former president of the New Hampshire Academy of Family Practice. His commentaries on aging are part of the MetLife Foundation Journalists in Aging Fellows Program organized by the Gerontological Society of America and New America Media. The most recent of his five books is The Man Who Cried Orange: Stories from a Doctor's Life (iUniverse, 2002, available in English and Spanish).