Date: February 1st, 2004
Those inclined to celebrate the just-passed huge and historic expansion of Medicare should pause in their champagne toasts to consider this: most doctors, nurses and other health professionals in the U.S. receive almost no formal training in geriatrics, which seriously undermines the quality of care - especially safe prescription drug therapy - for America's seniors.
It may be the biggest disconnect in American health care. The much needed Medicare prescription drug benefit will increase access to potent new medications. But what have we done to protect vulnerable seniors against widespread and often fatal misuse of current prescription drugs? Medical literature is replete with warnings of drug-related medical errors costing the nation tens of billions of dollars and upwards of 100,000 fatalities each year.
How do you safely and effectively increase access to medications for older people, when less than ½ of 1% of U.S. pharmacists are certified in geriatric pharmacology?
The new law will include a "welcome to Medicare physical exam" to new beneficiaries. Yet less than 1% of physicians in this country are geriatric specialists. Incredibly, the number of geriatricians is decreasing rather than increasing, just when the leading edge of the Baby Boom generation is little more than seven years from ballooning the Medicare rolls.
Challenge of Geriatric Care
Formal training to manage the complications of aging is just as scant among other health professions caring for the elderly-nurses, psychologists, physical therapists, social workers, dentists and occupational therapists.
The practice of geriatrics is not the easy road in medicine. Seventy-five year-olds on average take five different prescription drugs for three or more chronic medical conditions, as well as multiple over-the-counter remedies and nutritional supplements. Aging changes how the body metabolizes and clears drugs from the system. Symptoms of serious illness can present differently in older people.
Psychological and social factors, including the availability of caregivers, play an out-sized role in optimizing health care for older patients.
The well-prepared health professional treating older patients must be on top of all this complexity. This is a style of medicine, moreover, that is time-consuming, not particularly well paid nor seen as glamorous, especially to the young.
Not everyone over age 65 needs to get their health care from a certified geriatrician. But older patients will have better health outcomes, most likely with lower costs and fewer complications, if their primary care internists, family physicians, nurses and pharmacists have some basic geriatric training for age-related health problems.
The status quo in U.S. medical schools has to change and this may require leadership from Congress. Only five of the nation's 145 medical schools have departments of geriatrics. Only 10 percent of schools require coursework or rotations in geriatrics. Most schools offer this training as an elective, but less than 3% of medical students choose to take the courses.
The Urgent Call
In the past two decades there have been numerous governmental studies, Congressional hearings, and blue-ribbon committees and strategies on the geriatric shortfall. None has changed the growing gap between increasing numbers of older patients and decreasing success at infusing good geriatric practice into U.S. healthcare.
Better training of America's health providers to care for the elderly has obvious bipartisan and public appeal. It could be done at a tiny fraction of the cost of other Medicare changes. Until now, however, it is an issue that has failed to gain and hold political momentum. More contentious issues, such as prescription drug coverage, have dominated the Medicare debate.
By taking such a big step to modernize Medicare, Congress and the President have inadvertently highlighted one of the system's glaring shortcomings: the lack of basic training in geriatric medicine. Their job now is to fix it.