With today's post, Chapter 2 is complete. Chapters 1 and 2 have set the stage for the remainder of the book; a close look at the five challenges and their potential solutions. While some of my solutions may prove controversial, their debate, final form and transition into policy and law cannot wait another generation.
Chapter 2 (Part 3, Final)
A GREATER GENERATION?
4. Demand Knowledgeable and Sufficient Care
Here’s a fact that many in the medical community would rather you not know: they don’t know much about treating the elderly. Unless a medical student or resident is planning on being a geriatrician, the American system of training doctors almost completely ignores the unique needs of the elderly. If your reaction to this fact is “So what, I’ll just get a geriatrician when the time comes,” you are in for an unpleasant surprise. Geriatricians are a rare and shrinking breed in America. You are unlikely to find one. This situation is a result of relatively low pay for geriatricians, ageism and the issue of professional status.
Compared to their specialist peers, who routinely earn $500,000+ per year, the geriatrician, similar to the family doctor or pediatrician, can expect to earn only about 1/3 as much. When many young MDs emerge from med school owing hundreds of thousands in student loans, there is little monetary incentive in becoming a geriatrician. And, our medical students and residents are not immune to the issue of ageism; old people with multiple complaints are just going to get older and develop other complaints. Then, there is the issue of professional status, where the pecking order surely does not begin with doctors whose specialty is geriatrics; it doesn’t sound glamorous and, relatively speaking, it doesn’t pay that well. Deborah Chase’s internist was not sufficiently schooled in geriatric depression and his ignorance ruined at least a year of her life.
The demographic realities of America indicate that all physicians should be schooled in the basic aspects of health care for the elderly. Geriatric medicine is different in the same way that pediatric medicine is different. The training issues and pay disparities must be addressed through policy solutions.
Broadening geriatric medicine expertise will reduce health care costs by reducing the current mistakes in diagnosis or treatments that occur because a clinician doesn’t know that the aged often present symptoms and react to treatments quite differently than younger patients. At the very least, all 131 American medical schools should include an expanded, recurring and required geriatrics curriculum, regardless of the student’s declared specialty. For most of them, treating elderly patients will be a given not an option. Such schooling would also have a moderating effect on the issue of professional status as clinicians come to appreciate the complexities of dealing with the health issues of aging.
America already has a nurse and nurse’s aide shortage, especially for those serving the dependent elderly. The trend of producing qualified new ones is down and we’re only 22 years away from the first of the Boomers turning 85. Without a measurable reversal in this situation, there won’t be enough qualified caregivers (RNs, LPNs and nurses aides) available to provide the help many Boomers will need to live dignified lives when they are dependent on help. This shortage will mean rationing of assistance and/or care provided by the inept and ill-trained.
Although better than the geriatric educational in America’s med schools, the amount of geriatric training in America’s nursing colleges falls short on two fronts: (1) the shortage of classroom space and instructors to train nurses of all types, including geriatric nurses and (2) the same issues of ageism and professional status that plagues the med schools. Creating classroom space for the 92,000 qualified nursing school candidates who are turned away every year will be easier than training the trainers to teach them. The latter will require changes in policy and the creation of financial incentives for some nurses to teach rather than to nurse, a decision that is often driven by pay differentials.
While there are enough candidates for nurse’s aide jobs now--as there will be in the future--the poor working conditions in which aides are often asked to build a career, for meager pay and low professional status, attract only the most altruistic or desperate. If this were not so, the average annual turnover rate for nurses aide workers in geriatric settings would not be 85%, a number that does not reflect career satisfaction. The solutions for this particular problem involve issues of more and better candidate screening, working environment improvements, training, job status, career path and pay, and immigration policy.
5. Eliminate Lingering, Lonely and Painful Dying
The irony of the incredible advances in medicine in the past century is that these advances have turned death into a medical failure, even for the very old and very sick. With one or two arguable exceptions, for every recorded human birth in history, there has been a related human death. Up until about 1950, old age was but one of many causes of death, e.g. child birth, heart attack, pneumonia, cancer, stroke, the flu, the plague, polio, accident, ruptured appendix, infection, et al. Today, old age and its related vicissitudes—which, individually, get the credit on the death certificate--dominates the “cause of death” paradigm in America. Sure, the other causes of death still remain but the bulk of Americans now die because their systems simply wear out with age.
The human body can now -- with mechanical and chemical aids -- continue the processes controlled by the lower brain stem; respiration, circulation, digestion and elimination, long after the higher brain functions of communications, memory, emotion, muscle control, senses, etc. have disappeared, never to return. The fact that 80% of Americans now die at an advanced age, in small undignified steps, in institutions surrounded by well-meaning strangers (instead of at home, where over 93% of Americans claim that they want to die) illustrates the problem. What we want and what we get at life’s final milepost are completely different.
Today, once the old and terminally ill enter the health care system, the choice about the nature of their care is usually out of their hands. The end-of-life health care choices are complicated by the following: confusion about who is to make decisions on behalf of the incompetent dying patient, newly available medical alternatives, ethical dilemmas, religious beliefs, cultural taboos, legal precedent and, most importantly, ignorance of the patient’s wishes.
Perhaps the biggest reason that the very old have such a low chance of experiencing the dying process they might want is the distancing between physicians and their patients. This disconnection means that many physicians, particularly specialists, don’t know the patients under their care very well. If a family doctor is involved but hasn’t had a specific “end-of-life” discussion with the patient, their end-of-life care input is trumped by the specialists. Deborah Chase’s internist is a case in point. This situation has been created by the emergence of specialized and more complex medical alternatives, Medicare’s cure versus care bias and woeful confusion or ignorance regarding the nature and intent of living wills, health care surrogates, Do Not Resuscitate orders and Advanced Medical Directives
If Boomers want better options for their own end-of-life care, whether it is “Do everything possible to keep me breathing regardless of the consequences” or “Let me be comfortable, unafraid and at peace with the outcome,” then Boomers need to help create and support sensible end-of-life health care policy, greatly expand and refine the use of advance care directives, demand better end-of-life health care training for clinicians and promote insurance reimbursement for care expenses not just cure expenses. These changes should come from a recognition by the public and the health care system that dying is eventually a natural process for the very old, not an enemy to be vanquished. The real villain is a dying process that needlessly prolongs suffering and/or robs people of the dignity each deserves.
Having a national policy that encourages citizens to consider these issues and talk with their physician about their end-of-life care wishes is the antithesis of the notion of “death panels”, a patently ludicrous fiction promoted by the hopelessly paranoid.
Becoming a Great Generation
The five challenges outlined are daunting. It will take wisdom, courage and strength to take them on. There will be sacred cows to herd. Large and moneyed lobbies will rear up to oppose the process. Some influential but cowardly politicians will regard power as more important than the common good. There will be well-meaning but wrong-headed opponents and proponents clouding the issues with their own religious, spiritual or personal objections. There will certainly be defeats, self doubts, contentious viewpoints, heated debates and strange bedfellows along the way. What, you thought this would be easy? Well, it’s easier than wading ashore under withering fire at Omaha Beach on the morning of June 6, 1944.
And, should the Baby Boom take up the call and succeed, it would not be classy to seek accolades. We should take on these challenges simply because they desperately need to be done; right now. Someone has to take the lead and it is our turn.
In the following chapters I will elaborate on the nature of the challenges and suggest solutions, but mine aren’t the only ones. My goal is to give you ideas about how you can help move the agenda for change along. We must act now or the necessary changes will not happen. Unless you and I and Deborah Anne Chase individually decide now to put our support and influence into improving the systems, institutions and attitudes related to dependent living alternatives, entitlement programs, unnecessary costs, geriatric health care and end-of-life care in America, the same dysfunctional system is awaiting our arrival. Considering how much of our lives has already been lived, that future is very close.
Observoid of the Day: Freud said, "We cannot imagine our own death." Nevertheless, Freud is dead.