My ideal primary care physician (PCP), beyond being a skilled and intuitive doctor, has training in geriatrics and a practice that accommodates slow-moving seniors. Her office staff is polite, discreet, and helpful.
She responds to email inquiries and calls to her office are answered by a person, not a menu. She’s a good listener, open to alternative medicine, skeptical about pharmaceuticals, and not too opinionated (except where her opinions agree with mine). She won’t retire while I still need her.
Ideally, everyone would have a PCP who knows them well and who they trust and feel comfortable with. This doctor would be part of their health care team until the end of life, coordinating care and reining in specialists who treat isolated parts.
Unfortunately, this ideal is increasingly beyond reach, and the older we get, the more so. Instead of having doctors who know us and care about us, we’ll be known through our electronic medical records. When we end up in hospitals and facilities, we’ll be seen by hospitalists and facility doctors to whom we’re just another old person, or less than that, a “chart.” There’s got to be a better way. (Your Suggestions?)
Limitations on Choice
Your choice of physicians depends partly on your Medicare arrangement and partly on where you live. The larger the city, the more choices you’re likely to have, especially as a young old person. On the other hand, though choice may be limited in smaller cities and rural areas, you’re less likely to be seen as an anonymous chart if you end up in an emergency room.
Most people with Medicare Advantage policies are limited to practitioners in their “network.” Since networks can stop contracting with individual doctors at will, you could find yourself seeking a new doctor at any time. In smaller cities, there may be few available choices.
In addition, a drastic shortage of PCPs and General Practitioners (GPs) is projected for the future. This means that when your current doctor retires, he or she may be hard to replace. There are dire warnings that doctors will refuse to take on new Medicare patients, though this is not yet a common occurrence. (Still, if projected doctor shortages occur, it’s a possible scenario.)
It seems likely that nurse-practitioners and other not-quite-MDs will fill the breach, which may turn out to be a good thing. What’s most important is that they have a geriatric mindset and a senior-friendly office staff and environment.
A Geriatric Mindset
In a fascinating article, The Way We Age Now, Dr. Atul Gawande compares how a regular doctor like himself and a geriatrician look at old people.
For most doctors, the goal is a cure, or at least a remission. Losing a patient is a “defeat” in the “war” against death and disease. As you can imagine, many doctors are uncomfortable dealing with older patients, who ultimately can’t be saved.”
In contrast, geriatricians have accepted that death is inevitable and focus on helping people retain their quality of life.
Gawande discusses watching a geriatrician meet with an elderly patient who had colon cancer, advanced arthritis, and a variety of lesser afflictions. From Gawande’s perspective, the colon cancer, as the most serious, should be the first problem addressed, followed by the patient’s arthritic back pain. But the geriatrician hardly mentioned either of these conditions. Instead, he focused on examining the patient’s feet and reviewing her medications.
Gawande describes the session: painfully slow, conversational, attentive to mundane things like toenails. Not what most doctors would find satisfying. Not what most doctors would even consider medical (i.e., part of their job).
Doctors who focus on curing diseases generally ignore such “non-medical” matters as where a patient stays after a procedure, who picks up their medications, and who helps them bathe. (This mindset is responsible for Medicare’s failure to cover most aspects of long-term care.) But, as Gawande notes, since the geriatrician’s priority is keeping seniors actively engaged in the world, attention to these “non-medical” aspects of care is essential.
Gawande describes an experiment involving a sample of 568 men and women over the age of 70 at high risk of becoming disabled. Half were randomly assigned to see geriatric specialists instead of their regular doctors. The 18-month death rate was the same for the two groups, but there were many differences. Patients treated by geriatricians “were a third less likely to become disabled and half as likely to develop depression. They were 40% less likely to require home health services.” I know which group I’d want to be in.
Most Doctors Don’t Get It: It’s Normal for Old People to have Multiple Medical Problems
Our medical system has thrived by separating us into parts and studying those parts in detail. This approach is terrific when only one part goes wrong at a time. But when multiple parts are failing, as is increasingly common with age, being shuttled among specialists has diminishing returns.
There’s growing agreement that the “divide and conquer” approach is unsuitable for geriatric patients. In fact, the most effective geriatric practices tend to be low-tech and high-touch. But the whole weight of the American medical establishment pulls in the opposite direction. While many people – maybe even most – would support the geriatrician’s approach after a certain age, incentives and rewards continue to promote high-cost, high-tech, and high-risk approaches, partly because there aren’t enough geriatricians to put a stop to it.
Gawande and others discuss the many disincentives currently keeping doctors from specializing in geriatrics, ranging from inadequate pay to the inherent nature of the practice. Currently, there are fewer than four geriatricians per 10,000 older Americans, and this number is dropping even as the number of seniors grows.
And not only are geriatric specialists a rare breed, PCP/GP type doctors with geriatric training are also rare. And specialists with geriatric training are rarer still, so old people with multiple ailments are often treated by practitioners who are clueless about old age. (Projected Future Need For Geriatricians; Geriatrician Shortage Unlikely to be Remedied)
Of course this could change as a result of incentives and market forces. For example, if Medicare were to give bonuses to geriatric oncologists, cardiologists, pulmonologists, etc., we’d probably see more of them. But studies reliably show that the least costly alternatives often produce the best results (when measured by quality of life rather than months of survivorship).
We need to pressure Medicare to provide more home health services as well as incentives for GPs, specialists, and other medical workers to seek out geriatric training. Since this is likely to result in fewer high-tech procedures as well as with fewer emergency room return visits, it would seem a no-brainer. Better training, working conditions, salaries, and career paths for home health aides would also improve services, and maybe even costs.
Why is redirecting health care monies from overpaid specialists to lowly personal aides such a hard sell? Mainly, of course, because there’s no one selling it.
Movement Toward Coordinated Care
There are some positive developments.
First, it’s been noticed that some establishments with above-average results and below-average costs do things differently. A prime example is the Mayo Clinic, where doctors receive salaries and have no incentive to prescribe costly treatments. In addition, doctors work in teams and collectively take responsibility for each person’s care.
Some Medicare Advantage providers are experimenting with this model. CareMore, for example, has invested in “Centers” aimed at providing “one-stop shopping” for all outpatient needs. It’s currently available in California and Arizona, and targets low and middle income individuals. It will be interesting to see how patient satisfaction and outcomes compare to more traditional approaches.
Medicare is also funding experiments involving care coordination: See Innovation Center for more information.
Another positive development has to do with pharmaceuticals. Since remedies for any single condition are likely to have a systemic affect, multiple medications for multiple single conditions have a high likelihood of undesirable interactions. Pharmacists are now prepared to review an individual’s array of medicines and point out possible negative combinations. Such a review is a good idea whenever you start a new medication.
The future of geriatrics may be coordinated care, but in the present, it remains the exception. Beyond medications, most older people would benefit from having an individual who keeps track of their multiple medical problems and treatments. This would be the natural function of a PCP. A good PCP with geriatrics training wouldl see you as a whole person, keep track of your multiple problems, ward off predacious specialists, and be alert for potential treatment interactions.
In larger cities, independent providers of health care coordination are setting up shop, often staffed by retired nurses. These services are generally not covered by Medicare and can be quite expensive, but may be worth paying for if you can them. Some Medicare Advantage plans (like CareMore) are building care coordination into their array of services. And many Medicare Advantage plans require you to have a PCP, presumably for just this purpose.
Resisting the Rush to Treatment
In a thought-provoking book, Rethinking Old Age, Dr. Nortin Hadler inveighs against the “medicalization” of aging, which is, after all, part of the normal life cycle. He states that doctors are so set on treatment that they’re unable to absorb a large body of evidence showing that many common treatments are of little value and even harmful for older patients. He calls most surgery on people over age 85 “minor medical malpractice.”
Hadler recommends that while we’re still in our young old age, we take pains to find a doctor with good clinical intuition who’ll be with us for the long haul. Absent that, and even with that, we should be strong-minded and skeptical, questioning proposed treatments and not being swept up in [by?] a medical professional’s desire to do something. The best treatment may be waiting for the problem to go away on its own, which research shows it often does.
Sadly, we must approach our for-profit health care system with a “let the buyer beware” attitude, asking about low-tech alternatives and insistingt on knowing the percentage of people for whom a treatment is successful, its possible side-effects, the reliability of evidence supporting the treatment, and what happens if the treatment fails. Medicare will cover second opinions, and if the two opinions different, they’ll usually allow you to get a third opinion.
Finding a Senior-Friendly Doctor with a Senior-Friendly Medical Practice
If I needed complex surgery, I’m sure my top concerns would be the surgeon’s skill and experience. But if I’m not anaesthetized, the doctor’s personal qualities are important. These include being a good listener, looking directly at me when they speak to me, not being defensive about their own judgments, being open to experiment, and being willing to consider alternative therapies.
The National Institute on Aging offers excellent advice for choosing a doctor, including questions to ask the office staff. In my experience, the office staff will be at least as important as the doctor in determining your satisfaction with the care you receive.
One of the most important questions the office staff can answer is how long the doctor typically spends with each patient. The older we get the slower we get. It’s annoying to have a doctor who’s always in a hurry when you’re 50, but it’s worse than annoying and possibly dangerous when you’re 80.
Here’s my personal list of what to look for in a PCP, or really, any doctor. Medical competence and geriatric training are assumed.
- The doctor is willing to communicate via email. Once you experience this, you won’t willingly go without it. With my previous doctor, getting a question answered could easily take over a week if you left a message: two days for someone to call you back; two more days for them to call back with an answer to your question; two more days because you have a follow-up question or your original question was misunderstood, and on and on. Now my questions are answered within a few hours.
- When you call the office, a person answers the phone, not a menu. My current doctor passed this one with flying colors when I chose her, but has recently adopted an excruciating menu system. I’m hoping email will enable me to avoid using it again ever. .
- During an appointment, the doctor takes time with you. My former doctor typically saw four or five patients at the same time by running from examining room to examining room. She never sat down. If you had a last question after she was done with you, you were out of luck.
- The doctor is open to patient input and alternative medicine, and has time to explain things.