Chapter 28: Forget Plastics, It’s Geriatrics!
Ten Pediatricians, One Geriatrician: What’s wrong with these numbers?
I have a godson whom I like a lot, with whom I’m close and whose career I’ve followed with great, if not always selfless, interest. When in university his direction first turned to medicine, I was positively elated at the thought of a doctor in the family. For a while though, he thought he might become a psychiatrist, like his dad. Horrified, I sat him down and said: “Listen, the chances of me flipping my lid one day are pretty slim but the chances of me dying from some horriblo-gastrointerno stress-related something or other is probably pretty high, so if you’d like to have someone pay for your car and gas while you’re at med school tooling back and forth between Montreal and Toronto, why not learn something practical?”
Whether it was my subtle bribe that was the deciding factor (or the girlfriend back home), he did eventually pass on psychiatry. At which point I pounced and made my big pitch, my personal recreation of that famous scene in the movie The Graduate, where the middle-aged guy corners Dustin Hoffman at a cocktail party and gives him the big tip: plastics as the new sure-fire career choice. My version of plastics? Geriatrics! This, I told my godson, was the coming bonanza of medical specialties. I plied him with boomer demographics, the growing market, the inevitable demand soon to explode. Of course, I added in passing, I would, ahem, expect some special personal care when my time came. My presentation, I don’t mind saying, was truly impressive.
I bring up this story not just to give you a laugh (hopefully) but to highlight a situation that affects us all in a more serious and far-reaching way. This is the strangely neglected state of geriatric medicine in Canada. We hear endlessly about the health-care crisis our demographic will shortly inflict on society by flooding doctors’ offices and nursing homes and hospitals in record numbers and bankrupting the nation. But, if that’s so, how come no one mentions the concomitant and alarming shortage of medical personnel trained in the treatment of that coming flood?
According to the most recent Canadian Medical Association (CMA) count of physicians by specialty, there are currently 2,372 pediatricians practising in Canada – and 230 geriatricians. This is a ratio of 10 to one in favour of kids. The 2011 Canadian census records that there are 7,785,480 Canadians 19 years of age and younger, and 4,945,055 Canadians 65 years of age and older. This means that for every pediatrician, there are about 3,000 potential patients; but for every geriatrician, about 21,000 potential patients. I asked Dr. Barry Goldlist, a University of Toronto professor of medicine, the head of geriatric services at the University Health Network and past-president of the Canadian Geriatrics Society, how many new geriatricians Canada’s medical schools graduate every year? Approximately nine, he says.
How did this happen? The most generous explanation is social lag, with the medical profession mimicking the ad industry in being woefully slow to adjust to the fact that the huge boomer generation is no longer having children and is, in fact, aging. But the blame also rests with public perception of the two specialties.
The first perception is the obvious one: babies are cute and generally smell nice. Old people can be fading, cranky and malodorous. Who wouldn’t enjoy treating babies (and youth in general) more? Well, geriatricians. In a 2006 national physician survey published by the CMA, allergists and immunologists reported being happiest with their profession; geriatricians were second. “It’s a fascinating field,” says Goldlist, “and you can make a huge difference in people’s lives.”
Just how huge a difference is the passion of Dr. Colin Powell – not that U.S. Gen. Colin Powell – but the member of the CARP Advisory Board who works in University of Calgary’s geriatric division. Powell thinks that neglect of geriatrics is largely the result of ageist misconceptions. “One problem for doctors in treating older people is that we see somebody older and in trouble in front of us, and we automatically wonder, ‘Is that going to be my own old age?’ ” Physicians also invoke the bang-for-the-buck argument. “A doctor will look at an elderly patient and think, ‘If she’s 82, why bother? I can’t make her 28 again. If her problem really is age, it’s irreversible and untreatable.’ ” Which, insists Powell, is not always true. An anesthesiologist he knew once thought the practice of sending elderly depressed patients for electroconvulsive therapy (ECT) was wrong-headed because the procedure took up an hour of operating room time. “ ‘Six OR hours for ECT for these people,’ said the anesthetist, ‘is the same as a pump case [a cardiac bypass]. Is it really worth it?’ ” Powell got the anesthetist to come to the next scheduled ECT and watch the results. “These were people who were changed profoundly. Many weren’t eating and, without treatment, would have died within four to six weeks. The ECT saved them.” And converted the anesthetist.
Cost is another popular excuse for neglecting geriatrics; the funding for special new programs, it’s argued, will just put more pressure on an already strained system. In fact, investing in geriatrics in advance of the tsunami might be the best remedy because it directs patients to a more affordable and efficient level of care. Vancouver General Hospital recently introduced an acute geriatric unit for people over 75. Patients treated in the unit have shorter average stays in hospital and recover quicker.
The other half of the cost equation, though – what doctors get paid – may be the real monkey wrench. Geriatricians first have to specialize in internal medicine – a four-year stint after graduation – then take a further two years to subspecialize in geriatrics. The average annual salary for a general internist in Canada is about $297,000 (before overhead and other deductions). However, most geriatricians, despite having more training, make much less than this because only seven per cent of them receive the bulk of their income from the most lucrative medical source in Canada: fee for service. Geriatricians tend to be on fixed salary or service contracts (at hospitals, retirement facilities or as consultants). By contrast, 75 per cent of dermatologists reap most of their pay from fee-for-service, with a resulting yearly average of between $350,000 and $400,000. Ophthalmologists, whose training takes roughly as long as geriatricians, clock in at about $500,000 yearly. “Medical residents,” says Goldlist, “know the average income of specialists and subspecialists down to the penny. It’s not that they don’t like geriatrics but they may like another specialty equally and choose that one because it pays better.”
So why, you may ask, would any young person go into gerontology or geriatrics? Daniela Friedman is a 33-year-old Canadian-born academic, now assistant professor in the department of health promotion, education and behaviour (specifically for older people) at the University of South Carolina. Her original goal was to become a geriatric psychiatrist (shades of my godson!), but she settled on a PhD in health studies and gerontology at the University of Waterloo before making her move to the States.
“My main influences growing up,” she explains, “were septuagenarians – my grandmother who lived with us for many years until she became too frail to be without full-time medical care; and the pipe-smoking music teacher I visited once a week through my formative years. They were two of my biggest role models and mentors.” None of this might have mattered, though, if Friedman hadn’t also started volunteering as a teenager at Baycrest in Toronto, singing and playing the violin for aging residents there. Previously in this space, I’ve written about the uncanny bonds that develop between children and seniors they visit in retirement communities and the unique young-old symbiosis that occurs during these intergenerational meetings.
It strikes me that this rapport might be a key factor in persuading more young medical students to consider the geriatric option. They may already be emotionally attuned to the specialty because they’re already attuned to us. They just don’t know it yet. It’s our job to reach out to them and pitch ourselves as an interesting, rewarding demographic of patients. In return for their treatment, we have wisdom and patience and a perspective on life (and sense of humour) to offer. Our activism shouldn’t stop there. “I commend the mobilization of seniors to help us [geriatricians] in both our remuneration-recruitment and in our academic-education endeavours,” Powell writes. “Seniors can do what we cannot do. They can tell provincial departments of health that they need geriatricians … they can say to deans of medical schools, ‘What are you teaching medical students and doctors-in-training about us?’ ”
The task is not impossible. In Sweden, with a population of only nine million, there are 500 geriatricians. (Canada would require 1,800 geriatricians to match on a per capita basis.) Britain has as many geriatricians as cardiologists, and their salaries are the same. Even in wage equity-loathing America, geriatricians (who have organized as a specialty separate from internists) do better than here. So, there is hope. Where our generation settles, business can’t be far behind. “When I tell other young people what my field of study is,” says Friedman, “they give me a look like I’m Mother Theresa. When I tell baby boomers about it, meanwhile, they tell me, ‘There’s a lot money in that field.’ Then they list their medical maladies.”
I plan to point this out to my godson – who, despite my eloquence, became an emergency physician – the next time I talk to him. I’ll encourage him to look at geriatrics again. “No one has yet written the Dr. Spock for Zoomers,” I’ll say. My godson happens to be married to a pediatrician. But there may be hope for him still – and for us.
Moses’ Zoomer Philosophy — which launched in ZOOMER Magazine in October 2009 — is a series of monthly essays on age and aging, and the secrets and the science to living better, longer, healthier and happier lives. The first volume of his collection is now available in e-book format on the Kobo Books website. Click here for more information.