Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself” ”” confused and unsteady, unable to get out of bed.
She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s, but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.
Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won’t hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she’s considered ready for discharge ”” but she is no longer the woman she was before her illness. She’s more frail, and needs help with walking, bathing and daily chores.
This shouldn’t happen. All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics….
Dumb article. It really steams me when people start mandating so many hours of medical education for this or that. How much is designated for ophthalmology issues? Zero. How much for ENT? Zero. Orthopedics? Zero. It is luck of the draw whether medical students will see a patient with an eye issue, etc. Then we have non-medical politicians saying there should be mandatory education in “gay medicine”, etc. (But don’t use politically incorrect terms like gay bowel disease or the terrible health ramifications of homosexuality – worse than smoking.)
No training in geriatrics? Most of the patients you take care of when you are doing internal medicine are geriatric patients. We see lots of older patients.
There is not a dose reduction for advanced age. Plenty of 80 year olds can kick my butt, healthwise. If you have some frail LOL (little old lady), sure you might decrease the dose. Does every one know that altered mental status workup include looking for occult infection? Of course.
those 80 year olds may be able to kick your butt, robroy, but their livers can’t always eliminate meds as efficiently as a younger person. hopefully I have as much a chance of being a geriatric patient as I had being a pediatric one, and I hope that when I get there, my medical providers don’t just see me as “some frail LOL”.
I’m sure he doesn’t see any of his patients as “just” anything. Most physicians see their patients as valuable human beings. That’s why they do what they do.
The other problem with this article is that it’s attempting to compensate for the fact that 15 years ago, physicians could acquire a specialty in geriatrics. My father was one of them. BUT . . the government cut funding radically for geriatrics care and my father no longer practices in geriatrics — he’s now in another specialty, since medicare and medicaid simply don’t pay for so much of the work he did in geriatrics.
So now there are bleats to force medical students to engage in further training on the specialty that the government does not wish to pay for.
Ah well . . . we’ll all get what we vote for, anyway.
Elanor, my point is to treat the patient. Compromised liver function is not really dependent on age but hepatitis status, alcohol history, etc. Similarly, renal function is dependent on diabetes, hypertension, etc. Age is really isn’t a factor per se.
But Elanor is right to be concerned. Our future medical care is bleak. The issue is not lack of geriatric patient exposure in medical school. Rather, the scary issue is the minimal interest in general internal medicine by medical students. See [url=http://www.reuters.com/article/domesticNews/idUSN0933725520080909 ]here.[/url]
As a fellow doc, I agree with robroy–a lame article. The majority of patients I took care of on my internal medicine rotations in med school, and during my internship, were elderly. A big chunk of the adult patients I take care of in the OR at the tertiary care hospital I work at are seniors. So, it’s not like physicians-in-training aren’t getting adequate exposure to geriatric patients; hell’s bells, our population is aging, so who does the author think ends up in the hospital more frequently??
Sarah and robroy also allude to one of the not-so-secret secrets in medicine today, one that scares the bejeebers out of me as a specialist (and eventual geriatric patient): the lack of incentives for MDs to go into primary care medicine, to say nothing of geriatrics. The same government that bewails the lack of “gatekeepers” for their proposed national health plan is the prime agent behind the deincentivization of general internal medicine, through the methods that Medicare sets values on medical services and procedures. Of course, I feel some small sympathy for my non-procedural colleagues, as Medicare and Medicaid also undervalue my services.
After single-payer care hits, we’ll all be reimbursed at the same niggardly rate, so it’ll all be good.
To robroy and Joshua 24:15: What’s so lame or stupid about spending half of one’s life in training and practice to treat an underserved population and then in an empathetic manner, reaching out to educate and enlighten others?
I believe the point of this article by Dr. Rosanne M. Leipzig is being missed, by declaring that there is no mandated training for ophthalmology, otolaryngology or orthopedics. Not every doctor is going to be responsible for the ophthalmologic, ENT or orthopedic care of their patients, but they are going to be responsible for the care of older adult patients.
Sarah1 mentions her father who surrendered his geriatrics specialty for another. Sadly, it is a known fact that geriatricians receive the lowest compensation for their work because it is not typically procedure-based, which undermines its “value.†Brandeis professor Dr. Stuart Altman said that our insurance system is “biased against doctors like geriatricians who concentrate on preventive medicine,†and Dr. Laura Mosqueda, a geriatrician from the University of California-Irvine, told MSNBC in 2006, “Working WITH patients is seen as having less worth than working ON patients.â€
Joshua states that a “big chunk†of his patients are seniors, “so it’s not like physicians-in-training aren’t getting adequate exposure…†and continues by posing the question “who does the author think ends up in the hospital more frequently?†With this statement and question, Joshua is actually corroborating Dr. Leipzig’s points: that exposure does not equal expertise, and less of our senior population would “end up†in hospitals if more physicians were armed with the skills and knowledge to prevent a lot of iatrogenic disease.
Only about 7,000 US physicians (about 1%) are certified geriatricians. This is exiguous, considering the population of older Americans should double by 2030. Perhaps sometime in the not-too-distant future, our nation will be hard-pressed to address this issue when it becomes a more recognized, harrowing problem. As a NY Times 2006 article so aptly stated: “Teaching hospitals graduate internists with as little as six hours of geriatric training. The mismatch between supply and demand should be of concern.â€
Because it is so difficult to differentiate between aging effects and disease effects, brain tumors, blood clots, hypothyroidism and vitamin deficiencies have all been mistaken for Alzheimer’s. A CT scan doesn’t show Alzheimer’s until the disease has well-progressed. And the NBC Today Show once explained in a segment on NPH (Normal Pressure Hydrocephalus), that it is a treatable brain disorder that primarily strikes senior citizens and is often confused with Alzheimer’s or Parkinson’s.
We need physicians who are prepared to care for this aging population. That’s precisely why the author was amongst participants representing 57 different US medical schools and representatives from the AMA, AAMC, CGS, AGS, SGlM and the AMDA – embodying the specialties of geriatrics, gerontology, internal medicine, family medicine, and psychiatry – who identified 26 competencies which fall into eight general categories: medication management; cognitive and behavioral disorders; self-care capacity; falls, balance, and gait disorders; healthcare planning and promotion; atypical presentation of disease; palliative care, and hospital care for elders. There exists an urgent need for a better model of eldercare which extends its reach beyond geriatrics alone: “All medical students need to take care of older adults well,” said G. Paul Eleazer, MD, director of USCSM geriatrics division. “Even pediatricians – who have grandparents taking care of grandchildren – should be able to recognize dementia in that grandparent.”
Zarowitz et al (2007) stated in the Journal of the American Medical Directors Association, “The cornerstone for improving patient outcomes is the discovery, translation, and integration of knowledge into practice. Given the vulnerability and susceptibility of frail elderly persons, the potential risk of failed clinical response or intolerable adverse effects can be great.†Indeed: take the case of a 97-year old woman as spotlighted in a 2006 NY Times article, who, overnight, stopped eating, went from mildly confused to disoriented and was unable to urinate. Her frantic family rushed her to the ER where doctors did invasive tests and then suggested surgery. The family brought her to a geriatrician – Dr. Rosanne M. Leipzig – who suspected a silent infection, and a course of antibiotics did the trick. This is why I am compelled to take issue with robroy’s statement: “Does everyone know that altered mental status workup includes looking for occult infection? Of course.†(I am sure the family of this “little old lady†would beg to differ with you, too.)
As a healthcare professional, the message I take away from this article is: How can physicians think OUT of the box if they don’t know what’s IN the box?
So beware, and be aware: that “little old lady†may one day wind up being your mother or grandmother.