Basic training for doctors
Rosanne M. Leipzig, M.D.
Often even experienced doctors are unaware that 80-year-olds are not the same as 50-year-olds. Pneumonia in a 50-year-old causes fever, cough and difficulty breathing; an 80-year-old with the same illness may have none of these symptoms, but just seem “not herself”— confused and unsteady, unable to get out of bed.
She may end up in a hospital, where a doctor prescribes a dose of antibiotic that would be right for a woman in her 50s but is twice as much as an 80-year-old patient should get, and so she develops kidney failure, and grows weaker and more confused. In her confusion, she pulls the tube from her arm and the catheter from her bladder.
Instead of re-evaluating whether the tubes are needed, her doctor then asks the nurses to tie her arms to the bed so she won't hurt herself. This only increases her agitation and keeps her bed-bound, causing her to lose muscle and bone mass. Eventually, she recovers from the pneumonia and her mind is clearer, so she's considered ready for discharge — but she is no longer the woman she was before her illness. She's more frail, and needs help with walking, bathing and daily chores.
This shouldn't happen. All medical students are required to have clinical experiences in pediatrics and obstetrics, even though after they graduate most will never treat a child or deliver a baby. Yet there is no requirement for any clinical training in geriatrics, even though patients 65 and older account for 32% of the average doctor's workload in surgical care and 43% in medical specialty care, and they make up 48% of all inpatient hospital days.
Medicare, the national health insurance for people 65 and older, contributes more than $8 billion a year to support residency training, yet it does not require that part of that training focus on the unique healthcare needs of older adults.
Medicare beneficiaries receive care from doctors who may not have been taught that heart attacks in octogenarians usually present without chest pain, or that confusion can be due to bladder infections, heart attacks or Benadryl. They do not routinely check for memory problems, or know which community resources can help these patients manage their conditions. They're uncomfortable discussing goals of care, and recommend screening tests and treatments to patients who are not going to live long enough to reap the benefits.
I was part of a group of doctors and medical educators who recently published in the journal Academic Medicine a set of minimum abilities that every medical student should demonstrate before graduating and caring for elderly patients. Nicknamed the “don't kill Granny” list, it includes being able to prescribe medicines, assess patients' ability to care for themselves, recognize atypical presentations of common diseases, prevent falls, recognize the hazards of hospitalization and decide on treatments based on elderly patients' prognosis and their personal preferences.
The 2008 Institute of Medicine report “Retooling for an Aging America” resolved that all licensed healthcare professionals should be required to demonstrate such competence in the care of older adults. But this resolution lacks teeth. Medical resident training programs that receive Medicare money should be required to demonstrate that their trainees are competent in geriatric care. Medicare should finance medical training in nursing homes. And state licensing and medical specialty boards should require demonstration of geriatric competence for licensing and certification.
Basic geriatric knowledge is preventive medicine. Nurses, social workers, pharmacists and other healthcare professionals should have it, too, in order to improve care for older people. But until doctors get this basic training, we can't even begin to give 80-year-olds the care they need.
Rosanne M. Leipzig is a physician and a professor in the Brookdale Department of Geriatrics and Adult Development at Mount Sinai School of Medicine in New York.