Thursday, 03 May 2007
Our Elder Bodies, Our Elder Selves
Chad Boult, who is a professor of geriatrics at Johns Hopkins University, was asked recently what can be done to ensure that there are enough geriatricians as the elder population grows in coming years.
"'Nothing,' he said. ‘It’s too late.’ Creating geriatricians takes years,” continues writer Atul Gawande, “and we already have far too few. This year, just three hundred doctors will complete geriatrics training, not nearly enough to replace the geriatricians gong into retirement, let alone meet the needs of the next decade.” [emphasis added]
- The New Yorker, 30 April 2007
Gawande, an assistant professor of surgery at Harvard Medical School, spent time sitting in on examinations of elder patients with his hospital’s chief geriatrician, Juergen Bludau, and visiting with 87-year-old, retired geriatrician Felix Silverstone whose lifetime passion has been to understand human aging.
The result of Gawande’s time and effort is an extraordinary piece in last week’s New Yorker titled “The Way We Age Now” which is stuffed with facts about aging in America today. The section on falls in the elder population alone is particularly enlightening:
- Each year 350,000 Americans fall and break a hip
- Of those, 20 percent (70,000) never walk again
- 40 percent (140,000) will end up in a nursing home
- The three primary risk factors for falling are poor balance, taking more than four prescription medications and muscle weakness
- Elderly people without these risk factors have a 12 percent chance of falling in a year
- Those with all three risk factors have almost 100 percent change of falling in a year/li
Gawande also explains that the complexity of treating old people takes time, patience and lacks the glamour of other specialties. Sometimes seeing that an elder’s toenails and calluses are regularly trimmed contributes more to health – and preventing falls - than medication:
“The job of any doctor, Bludau later told me, is to support quality of life, by which he meant two things: as much freedom from the ravages of disease as possible, and the retention of enough function for active engagement in the world. Most doctors treat disease, and figure that the rest will take care of itself. And if it doesn’t – if a patient is becoming infirm and heading toward a nursing home – well that isn’t really a medical problem, is it?
“To a geriatrician, though, it is a medical problem…”
Unlike too many anti-aging gurus and “elder coaches” on the web, Dr. Gawande is a realist:
“Decline remains our fate; death will come. But, until that last backup system inside each of us fails, decline can occur in two ways. One is early and precipitately, with an old age of enfeeblement and dependence, sustained primarily by nursing homes and hospitals. The other way is more gradual, preserving, for as long as possible, your ability to control your own life.
“Good medical care can influence which direction a person’s old age will take. Most of us in medicine, however, don’t know how to think about decline…Give us a disease, and we can do something about it. But give us an elderly woman with colon cancer, high blood pressure, arthritic knees, and various other ailments besides – an elderly woman at risk of losing the life she enjoys – and we are not sure what to do.”
What is worse, is that there will be fewer geriatricians who have any idea how to treat us as the number of elders increases in coming years. Dr. Gawande also tells us:
- The number of certified geriatricians fell by a third between 1998 and 2004.
- Applications for geriatric training programs are plummeting while applications in the fields of plastic surgery and radiology have reached record numbers
It is not just scorn of those who believe they can turn back the clock with plastic surgery that leads to so much effort expended at Time Goes By writing about the futility of it. It is the risk of having no physicians with the knowledge to treat elders’ real medical problems.
It is a supply and demand issue. If aging people by the millions were not demanding to be made into facsimiles of youth, doctors would not choose plastic surgery as a specialty. If we brought to bear the same pressure against plastic surgery as has been given to anti-smoking campaigns and nowadays, the burgeoning environment movement, elders would have a chance of finding educated, experienced geriatricians to help them live independently as long as possible.
Until that happens, we elders are on our own. We must keep ourselves educated and up to date on the finer points of elder health - such things as why keeping toenails and calluses clipped helps prevent falls and why it is important to discuss fewer prescription medications with our (non-geriatrician) physicians if possible.
To that end in this little corner of the blogosphere, I have undertaken a search for a practicing geriatrician who will write a bi-weekly column for Time Goes By with that kind of advice. I hope that will be done soon.
Remember what Chad Boult, the professor at Johns Hopkins, said about what can be done to ensure that there are enough geriatricians to serve the elder population:
“Nothing. It’s too late.”
[Speaking of health issues, Chuck Nyren has contributed a story at The Elder Storytelling Place today that he has bravely titled The Slobberer.]