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Friday, Apr 20, 2018
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Who will care for an aging generation?

When Mary Sterling faces an obstacle, she remembers her mother's credo: You come from a long line of strong, independent women.
Now that Sterling is in her 80s, that advice resonates more than ever, especially when it concerns her health. She still lives in her own apartment and is able to drive. But being strong and independent doesn't mean the same thing as when she was in her 40s.
"I think we so-called living longer people have a myriad of problems," the Tampa resident said of the unavoidable changes that come with aging. "It takes someone with special experience to take care of us."
About a year ago, Sterling dropped her primary care doctor for a geriatrician, a physician who specializes in treating patients in their golden years. She says that physician listens more and asks more age-relevant questions than other doctors. Treating specific maladies is secondary to making her day-to-day quality of health better, Sterling said.
This sort of approach sounds appealing, but there are just a handful of these specialists in the Tampa area today. And there is little chance the numbers will improve, as many of today's medical schools, including the one at the University of South Florida, don't encourage students to focus on the nuances of treating a community's oldest members.
In 2007, the American Association of Medical Schools created minimum geriatric competency guidelines for all of the nearly 150 accredited medical schools in the United States and Canada. But how and what is taught to future physicians is inconsistent, especially in Florida, home to the nation's biggest percentage of residents age 65 and older.
Florida, like the rest of the nation, may never have enough trained geriatric specialists. But limited exposure to geriatrics risks creating another generation of primary care doctors who are ill-prepared to care for the state's increasingly older, longer-living population, said Ken Brummel-Smith, director of Florida State University's geriatric department.
"Just because (a physician) can take care of adults doesn't mean they can take care of the oldest adults," he said.
FSU's College of Medicine, founded in 2000 with an emphasis on geriatrics, is the only one of the state's six public medical schools that requires academic and clinical geriatric training in all four years of medical school.
Three schools, including USF, incorporate geriatrics into a single course or short clerkship that can last anywhere from a single afternoon to a month.
And two schools have no specific classes focused on elder medical care, but say they teach geriatrics in classes such as anatomy or health care policy.
"You're right. We can do more," said Stephen Klasko, dean of the USF College of Medicine.
Part of the problem stems from the relative youth of the geriatric field itself. It wasn't until the late 1970s and '80s that the medical community started to think of the diagnoses and treatments of conditions related to old age as its own branch of medicine.
Geriatrics, by definition, is a sub-specialty for doctors practicing family medicine or internal medicine. But these primary care physicians take more than medical diagnoses under consideration, said Laurence Solberg, chief of geriatric medicine at the University of Florida College of Medicine.
For example, a 40-something patient may not need to leave the exam table for a doctor to assess health concerns. But geriatricians will watch a patient stand and walk to assess critical functional issues such as balance and strength of sensory muscles. And understanding a patient's ability to complete daily functions - say, getting dressed or cooking - is as important as knowing the chemical risks of prescription drugs.
"Those kind of clues are always key to the geriatrician," said Solberg, whose program at UF requires fourth-year students to spend a month practicing geriatric medicine. "Is this person going to be at greater risk for a fall? Get in there and talk to the patient. You can synthesize the keys."
Traditional medical schools are slow to adapt curriculum to newer ideas, despite the rapid aging of the nation's population, said Elizabeth Bragg, a geriatric education expert and associate professor at the University of Cincinnati College of Nursing.
It doesn't help that geriatrics is unpopular among 20-something medical students, she said. Salaries are low and there's no glamour in treating elderly men and women with multiple, chronic and sometimes incurable illnesses such as dementia, osteoporosis and cardiovascular disease.
"There has to be a critical mass of interest to get programs to change," she said.
Michelle Estevez, the lone staff geriatrician at USF's medical school, lectures every year to the college's third-year medical students, hoping to spark their interest in people like her patient Mary Sterling.
"They like me because I have energy and I'm young, but I don't think any of them want to think about going into geriatrics," Estevez said.
It's an uphill battle in a program that requires only a short-term clinical geriatric clerkship for internal medicine students, she said. Next fall, the 35-year-old will have her lecture time shortened to just one four-hour session in which to change minds.
"Why, when you are in your 20s, would you want to deal with (what you imagine are) a bunch of 80-year-olds with diapers and dementia," she said of her patients, who on average are in their 80s. "But I love my patients. They are fantastic human beings."
Some geriatric medicine advocates say focusing on undergraduate medical training is the only way to serve an aging population in Florida and elsewhere. Specialists can't meet the demand of nearly 3.3 million seniors in Florida.
USF's Estevez is among just 424 certified geriatric specialists practicing in Florida today, and one of 7,500 nationwide, American Geriatric Society data show. That certification requires doctors spend an additional year in a geriatrics fellowship after completing a three-year medical residency.
You're going to school longer, but you're making less than colleagues in sub-specialties such as cardiology, Bragg said.
Only 144 geriatric fellows are practicing in the United States this year, and only four are in Florida, the Accreditation Council for Graduate Medical Education reports.
USF, which discontinued its geriatric fellowship several years ago, is looking long-term at geriatric medical training, said Klasko, the medical school dean and chief executive officer of USF Health.
He would rather focus on long-term projects, such as USF Health's primary care practice in The Villages senior community in Central Florida. In mid-June, USF Health announced that a $3.6 million gift will create a post-residency geriatric fellowship program there.
The new Villages fellowship, which is being developed, will eventually lead to more concrete training for medical students in Tampa, Klasko said. Lessons learned in the primary care practices at The Villages can identify better ways to care for older patients, he said.
"It will create an optimum environment for geriatrics," said Klasko, who will leave USF this summer to lead Thomas Jefferson University in Philadelphia. "It will lead to more geriatric classes."
In the meantime, Estevez said, she'll continue to cheer on any and all medical students who are the least bit curious about treating society's oldest citizens. And she will keep searching for that balance between treating her elderly patients' illnesses and helping them enjoy life the best they can.
"Every day, I make a couple of lives better," she said. "That's pretty good."
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Twitter: @MaryShedden
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