Illustration by Matthew Woodson
As the first wave of baby boomers begins to sign up for Medicare, there’s no end to the heated debate surrounding the healthcare system’s future. Kathleen Sebelius, secretary of the U.S. Department of Health and Human Services, recently predicted that roughly 3.3 million new beneficiaries would sign up for the program annually in the years to come.
But while financing such numbers has been widely discussed, the care itself is another matter—particularly in the field of geriatrics.
“The demand is growing, but the numbers are going down,” says Dr. John Morley, director of Saint Louis University School of Medicine’s Division of Geriatric Medicine and medical director of Des Peres Hospital’s Acute Care for the Elderly unit. “Here at SLU, we train roughly nine to 10 percent of geriatricians in the country—and we have for the last 20 years. There’s something wrong with that equation; Saint Louis University is not the biggest or most central university in the world, and yet we’re training a huge percentage of geriatricians. And what we’re finding now is that we can’t train the huge percentage anymore because people don’t want to go in.”
Part of the problem is financial, he says: “Geriatricians don’t earn what anybody else earns. If you’re going to spend an hour and a half with a person, as I did with two people in my clinic this morning, fundamentally a general internist will have seen 10 people and billed each of them the same amount as I billed the two.”
In other countries, the financial structure levels the paying field, motivating physicians to enter the specialty, he says. Perhaps it’s no coincidence then that about 60 percent of those who specialize in geriatrics are international medical graduates like Morley, who grew up in South Africa. “It’s really sad when you can’t find the majority of people going into a specialty being from America,” he says.
Perhaps another reason the field of doctors is still relatively small is the specialty’s age, which is—ironically enough—relatively young. Austrian-born physician Ignatz Leo Nascher first coined the term “geriatrics” in 1908, at a time when the concept “had no traction in the world or here,” says Morley. In England, the field gained popularity during the 1940s and ’50s, but it remained small in the U.S. until the mid-’70s, when the Veterans Health Administration launched the Geriatric Research Education and Clinical Centers to meet the demands of the aging population of World War II vets. (Morley is the director of St. Louis VA Medical Center’s GRECC.) Many geriatric programs have since grown from these centers, developing over just the past three decades.
“We’re where pediatrics was in the ’50s, before it started to evolve into a true growth area like general internal medicine,” says Morley. “This is a field that really, to some extent, is still trying to find itself, but has come an incredibly long way.”
Among its greatest achievements: “We’re one of the few medical specialties that has shown it actually works—we improve outcomes,” says Morley. Here, he makes a distinction: “Geriatrics focuses on improving function rather than trying to extend life. While life extension is useful, if you can’t function, it’s not nearly as useful.”
So who, exactly, should see a geriatrician? There’s not a simple answer. “I have people in their fifties saying, ‘Shouldn’t I come and see you because you can help me stop from getting old?’—and they’re usually highly functional, and I can’t do anything for them—to people who are 85 and say, ‘I’m not old enough to see a geriatrician,’” says Morley. “In an ideal world, somewhere around the age of 70, everyone would be referred by their physician to see a geriatrician once to make sure the person understands the difference between being 70 and 50.” He sees many older patients, for instance, who are deliberately losing weight, though that may put them at greater risk of a hip fracture.
“The [Centers for Disease Control and Prevention] tell us all the time that we need to lose weight. Over the age of 60, weight loss is almost always associated with an increase in death, so you’ve got to reach your right weight by the time you’re somewhere around 60,” says Morley. (Of course, every case is different, so it’s best to consult a physician when considering any weight-loss plan.)
Morley distinguishes between two general groups of patients: 1) those typically between ages 60 and 70 who can take preventative steps to better care for themselves and 2) older patients experiencing immobility, instability, incontinence, and impaired memory who should continue to see a geriatrician. “On the whole, mostly I prefer to see people and send them back to their primary-care physician,” he says, “then work with the primary-care physician to improve the outcomes.”
An author of more than 20 books on geriatrics-related topics, Morley gives lectures around the world on what he calls “aging successfully.” While he says much of his advice is common sense (e.g., encouraging patients to eat a balanced diet, rather than a handful of vitamins), he acknowledges some approaches to geriatric care are different than other medical specialties. He lists a few examples:
On Depression: “We spend a lot of time with people who are depressed or not happy, trying to improve their mood, because depression is highly associated with almost every disease and makes the outcomes worse.”
On Prescription Drugs: “The first thing I do most of the time is get rid of half of the drugs that people are on. A friend of mine in Australia showed very nicely with a mathematician that if you get on five drugs and your physicians wants to add a sixth, it’s got about the same chance of killing you as it has of making you better, so you’d better make sure that your physician’s sixth drug is really useful.”
One of the world’s foremost experts on Alzheimer’s disease, Morley also emphasizes the importance of maintaining an active mind. “Simple things can make a big difference,” he says. Playing chess or card games, for instance, helps improve outcomes. “You can simplify the games as the person gets more demented,” he says, “but keeping people active is very important.” Staying socially active is another key. “I had a patient today who said he’s not doing well, but what he’s doing is, he stopped socializing; if he can socialize again, I think he will be fine.”
A trip to the geriatrician often proves as helpful for caregivers as it is for patients, Morley adds. “I do a fair amount of permission-giving, saying, ‘Look, you’ve got a relative at this stage who has to be in a nursing home—there’s no way you can look after the person, have a job,
and do all these other things,” he says. “I believe that with support, you can live independently until it’s as dangerous as bungee jumping.”
Morley sees plenty of room for improvement—and certainly for growth—in the field of geriatrics, but he’s also encouraged by how the field has grown over the past several decades. “I think we’ve shown that we can keep people out of hospitals, we can keep them
out of nursing homes, we can improve their function, and we can keep them happier,” he says.
“That’s what geriatrics is about: I sort of think of us as happiness doctors. When we succeed at doing that, we have very good other outcomes as well.”
