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How medicine mistreats aged


Jane Gross’s piece on oldies quietly nails financial distortion of medical careers

Surgery planned for a complaint cured by antibiotics

A front page piece in the Times today points up the basic flaws in medicine today by showing how it fails to deal properly with aged patients. The cause of the problem: high technology makes it far more profitable to ignore the elderly, who usually don’t need it.

One old lady of 97 was probed and tested in a hospital to diagnose her sudden change in behavior, and then lined up for surgery – until a geriatrician recognised it was merely a silent infection, and cured her in days with an antibiotic.

But when Mrs. Foley saw a geriatrician at Mount Sinai Medical Center, surgery proved unnecessary. The geriatrician, Dr. Rosanne M. Leipzig, suspected a silent infection — something the other doctors had missed because Mrs. Foley had no fever, as old people rarely do.

Indeed, within days, antibiotics had done the trick. For the Foley family, it was a welcome result. They had reason to count themselves fortunate to have found a doctor who specialized in treating the elderly.

The piece by jane Gross is remarkable for quietly noting the basic flaws in the practice of medicine today that have come with expensive high tech equipment and the way in which it has influenced interns to choose superspecialities like radiology and orthopedic surgery – $400,000 a year – rather than geriatrics -$150,000 – even though the latter field is the most interesting, the most complex, and the most deserving of good minds.

The most memorable discouragement came during his residency, from a pulmonologist, Dr. Shah said.

“When I passed him in the hall, he would shake his head and mutter, ‘Waste of a mind,’ ” he said. “My retort was always that the geriatric population is often the most complicated, not only medically but also socially and psychologically, and that was exactly the specialization you should want your top students going into.”

The result is that most hospitals haven’t a clue how to diagnose elderly patients correctly. Judging from the article, the elderly would be better to steer clear of hopsitals as long as they can.

That lack of training can lead to misdiagnosis, because it is often tricky to tell the difference between physical, psychological and cognitive conditions in this age group. That was the case for Rita Zaprutskiy, 75, of Houston who went to the emergency room with a painful arthritic knee, had surgery, was given an array of pain medications and then seemed to lose her mind.

Four hospitalizations and six months later, Mrs. Zaprutskiy’s daughter said, the family was urged to put her in a nursing home because of severe dementia. Instead, her daughter, Yelena Schwarz, tried one last psychological evaluation, at a county hospital, and unwittingly wound up in a geriatric unit. There the doctors knew, from the sudden onset of her symptoms, that Mrs. Zaprutskiy did not have dementia, but rather treatable psychiatric conditions, including depression.

All in all, the article makes some terrific admissions and is a vivid description of how money distorts the shape of what used to be viewed as a vocation as much as a profession. Luckily hospitals are trying to correct the problem, including a novel program at the University of Oklahoma where elderly patients “regale” students at lunch with stories from their lives.

(show)

October 18, 2006

Geriatrics Lags in Age of High-Tech Medicine

By JANE GROSS

Margaret Mary Foley, 97, just wasn’t herself. Overnight, she stopped eating, went from mildly confused to disoriented, and was unable to urinate. When her panicked family rushed her to the emergency room, doctors did invasive tests, difficult for a woman her age, and then suggested surgery.

But when Mrs. Foley saw a geriatrician at Mount Sinai Medical Center, surgery proved unnecessary. The geriatrician, Dr. Rosanne M. Leipzig, suspected a silent infection — something the other doctors had missed because Mrs. Foley had no fever, as old people rarely do.

Indeed, within days, antibiotics had done the trick. For the Foley family, it was a welcome result. They had reason to count themselves fortunate to have found a doctor who specialized in treating the elderly.

Even as the population ages and more people like Mrs. Foley need them, geriatricians are in short supply. It is a specialty of little interest to medical students because geriatricians are paid relatively poorly and are not considered superstars in an era of high-tech medicine. In fact, the credo of geriatric medicine is “less is more.”

In 2005, there was one geriatrician for every 5,000 Americans 65 and older, a ratio that experts say is sure to worsen. Of 145 medical schools in the United States, only 9 have departments of geriatrics. Few schools require geriatric courses. And teaching hospitals graduate internists with as little as six hours of geriatric training.

The mismatch between supply and demand is “a troubling issue for us,” said Dr. Leo M. Cooney, a professor at Yale University School of Medicine. In a good year, Dr. Cooney said, one of 45 internal medicine residents decides to be a geriatrician.

The rest, he said, choose “super specialties” like cardiology or oncology. This, despite the fact that geriatricians reported the highest job satisfaction of any specialty in a 2002 survey in the journal Archives of Internal Medicine.

Interest is also low at the University of Oklahoma College of Medicine, which has a rare requirement that medical students do a four-week rotation in geriatrics. Eighty percent said it was time well spent, but less than 10 percent considered it as a career, said Dr. Marie A. Bernard, chairwoman of the geriatrics department. “They want to do laser-guided this and endoscopic that,” Dr. Bernard said.

Caring for frail older people is about managing, not curing, a collection of overlapping chronic conditions, like osteoporosis, diabetes and dementia. It is about balancing the risks and benefits of multiple medications, which often cause more problems than they solve. And it is about trying nonmedical solutions, like timed trips to the bathroom to improve bladder control.

But these are common-sense remedies in a health care system that rewards the heroics of specialists, in both compensation and prestige. The best-paid doctors are those who do the most procedures; radiologists and orthopedic surgeons top the list with average annual incomes of $400,000. Geriatricians, who do a residency in internal or family medicine and then a fellowship in geriatrics, are near the bottom, at $150,000 a year.

While fellow residents followed the money, Dr. Amit Shah, who had the luxury of no medical school debt, chose a geriatrics fellowship at Johns Hopkins University, despite being dissuaded by many people.

The most memorable discouragement came during his residency, from a pulmonologist, Dr. Shah said.

“When I passed him in the hall, he would shake his head and mutter, ‘Waste of a mind,’ ” he said. “My retort was always that the geriatric population is often the most complicated, not only medically but also socially and psychologically, and that was exactly the specialization you should want your top students going into.”

Reimbursement drives doctors’ compensation. Gastroenterology, for instance, became more lucrative — and popular — once Medicare, which sets the standard for most other health insurance, began paying for screening colonoscopies. Geriatricians joke that they are waiting for the invention of a geriscope, so that they too can bill for procedures.

Meanwhile, much of what they do — communicating with family members, discouraging unnecessary tests — is time consuming but not reimbursed.

Another disincentive is the lowly status of geriatrics at most of America’s medical schools, which expect more ambitious choices from top residents like Dr. Shah. In Britain, where every medical school has a geriatrics department, it is the third most popular specialty. Reimbursement there goes up with the age of each patient, a formula that improves compensation.

Historically, the explanation for not requiring geriatric training in this country has been that a majority of hospital patients are old, and thus doctors-in-training absorb what they need to know by osmosis. Nonsense, said Dr. Robert N. Butler, president of the International Longevity Center in New York and the first chairman of geriatrics at Mount Sinai. “All patients have hearts,” Dr. Butler said, “but that doesn’t make all doctors cardiologists.”

One proposed solution to the shortage is for geriatricians to limit their practice to the frailest of the elderly, generally those past 85, along with a subset in the 65-to-85 age bracket who have complicated needs. According to a 2002 study at Johns Hopkins University, 20 percent of those 65 and older have at least five chronic conditions.

Another solution, gaining a foothold among the nation’s top academic geriatricians, is to focus on teaching the core principles of their specialty to everyone, be they surgeons or discharge planners, because it is unrealistic to assume there will be enough geriatricians to go around.

“If we got to the point where everybody in the health care system was an expert in caring for older people, we wouldn’t need geriatricians,” said Dr. Cooney of Yale. “Or we wouldn’t need them as frontline providers. We’d be like consultants, making sure everyone else was as skilled as possible.”

Specialists, internists and emergency room doctors without sufficient training in geriatrics can pinpoint their own inadequacies. In recent surveys by The Journal of the American Medical Association, many said they were unprepared to deal with end-of-life decisions, communication with family caretakers, depression and other issues of aging.

That lack of training can lead to misdiagnosis, because it is often tricky to tell the difference between physical, psychological and cognitive conditions in this age group. That was the case for Rita Zaprutskiy, 75, of Houston who went to the emergency room with a painful arthritic knee, had surgery, was given an array of pain medications and then seemed to lose her mind.

Four hospitalizations and six months later, Mrs. Zaprutskiy’s daughter said, the family was urged to put her in a nursing home because of severe dementia. Instead, her daughter, Yelena Schwarz, tried one last psychological evaluation, at a county hospital, and unwittingly wound up in a geriatric unit. There the doctors knew, from the sudden onset of her symptoms, that Mrs. Zaprutskiy did not have dementia, but rather treatable psychiatric conditions, including depression.

One way to sharpen the skills of assorted specialists is to welcome them at continuing education classes for geriatricians. At a popular Mount Sinai seminar called “The Hazards of Hospitalization,” a nongeriatrician asked Dr. Helen M. Fernandez how she would deal with a 90-year-old woman in the emergency room with dizziness.

After hearing the woman’s history, Dr. Fernandez said she would fight against admission. “You need to be brave enough to march down to the E.R.,” she said, “and tell the attending she’s your patient and you want to peel her off some of her meds before doing a full cardiac work-up.”

In another course, “The 10 Minute Geriatric Assessment,” Dr. Fredrick T. Sherman told students to “get the focus off the stethoscope” and watch their patients move around. Can a woman get out of a chair without pushing off with her hands? That means she can still use the toilet. Can a man put on his socks? If not, he will soon need someone to dress and bathe him.

“We want to know what they can do and what they can’t do,” Dr. Sherman said. “That’s a better predictor of the future than a head-to-toe exam.”

A new form of geriatric training comes from elderly patients recruited as mentors, like Alberta Harris, 85, who lunches with students at the University of Oklahoma College of Medicine, regaling them with stories of her life. Residents learn other lessons when they visit the elderly at home. Many doctors consider family members impositions on their time. Seeing them as day-to-day caretakers makes it clear that in geriatrics, an adult daughter, like Mrs. Zaprutskiy’s, is an essential ally.

Ordinary floor nurses can also bring a geriatric sensibility to a hospital. An institute at the New York University School of Nursing helps small community hospitals identify nurses with an affinity for the elderly and provides them with a training curriculum and guidance on how that nurse can be a resource to others.

To increase the number of specialists, N.Y.U. and other nursing schools are building a cadre of geriatric nurse practitioners. Many work in hospital units reserved for the frailest patients, who can spiral downward quickly from a setback like a skin infection or a broken rib.

Mrs. Zaprutskiy was treated in such a unit, run by Dr. Carmel Bitondo Dyer of the Baylor College of Medicine. On a recent visit, while her daughter and doctor discussed the case, Mrs. Zaprutskiy played Russian and Yiddish folk songs on a piano in the day room, her crooked fingers moving gracefully across the keyboard.

Ms. Schwarz wondered if her mother’s psychiatric condition had been caused by medication. Dr. Dyer said there was no way of knowing for sure. But misdiagnosis and overmedication of the elderly is common.

“We see it all the time — elderly people who go from hospital to hospital with no results,” Dr. Dyer said.

“When patients are diagnosed correctly and care is managed accordingly, we see great improvements,” she continued. “Sometimes we don’t cure them; we just make them feel better. But that’s a good thing.”

Laura Griffin contributed reporting.

Copyright 2006 The New York Times Company

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