At Truman Medical Center’s nursing home facility in eastern Jackson County, Missouri, Dr. John Dedon drops by to chat with one of his patients, a spritely 82-year-old woman who’s lived there for the last four years.
“I’m just stopping by to say hi and see how you’re doing today,” he says, taking a seat next to her in the facility’s bustling hallway. “How are you feeling? Are people treating you O.K.?”
Dedon is probing, not just for physical symptoms, but also for changes in his patient’s mood and affect.
“I think you're in a good mood, and I think that you're doing great,” he tells her. “I'm happy that you're maintaining your quilting activity and that your functional status seems maintained.”
Dedon has been a geriatrician, a physician specializing in the care of older adults, for the last 25 years. This, despite the fact that he wasn’t interested in geriatric medicine when he started medical school 34 years ago.
“But as I was around older people, I became impressed with the mismatch between their multiple medical diseases and syndromes and the care I saw them getting,” he says.
Dedon, however, is one of just a few dozen geriatricians in the Kansas City area.
In 2010, there were nearly 219,000 adults age 65 and over in the nine-county Kansas City metropolitan area. That was 11.4 percent of the population. By 2030, the 65-plus population here is projected to grow to more than 416,000 people, or nearly 18 percent of the population.
In other words, there’s already tremendous demand to treat older people – and treat them appropriately. And that demand is only going to grow.
“It’s one thing to take care of a lot of old people,” Dedon says, “it’s another thing to do it in a manner that’s appropriate and standard of care.”
Yet it’s proving very difficult to attract people into the field. Health experts point to any number of reasons why that’s so: a perception that geriatric medicine doesn't pay as well; it isn’t sexy; there are rarely quick fixes to the ailments and co-morbidities that tend to afflict the elderly.
“And some people don’t like the idea of death,” Dedon says. “Some people don’t like the idea of complex patients. Some people don’t like the idea that they have to spend a lot of time with the patients.”
Marcia Walmer, a former clinical faculty member at the UMKC School of Nursing and Health Studies and a psychiatric nurse practitioner, says older adults come with a set of chronic issues, “and perhaps it’s not the type of challenge that providers overall want to manage.”
“It seems like for the past 40 years our country has really been trying to address this problem of increasing the geriatric workforce, and it’s been having the same issue over and over again: There’s just not a lot of interest,” she says. “And that is in every discipline.”
Walmer and her one-time colleague, Lyla Lindholm, are working hard to boost interest in the field among their students. Both acknowledge it isn’t easy.
“There still seems to be a lack of interest or value in practicing and serving older adults,” says Lindholm, a clinical assistant professor at the nursing school. “… And this lack of interest with older adults – it seems to extend throughout the whole team: the physicians, the nurses, the physical therapists, occupational therapists, speech and nutrition.”
So what’s to be done? The UMKC School of Medicine, where Dedon teaches, and the University of Kansas School of Medicine offer geriatric medicine fellowships every year. So do the University of Missouri-Columbia, Washington University in St. Louis and St. Louis University.
That’s the good news. The bad news: The slots aren’t filling. Nationwide there were 385 fellowships in geriatric medicine this academic year. But only half of them were filled.
Ann Marie Marciarille, a UMKC law professor who teaches healthcare law, says that even in her profession it’s difficult to get students interested in elder law.
“It's a tough sell to very young people who haven't, because we segregate by age in our society – by housing, by work, by so many things – some of them have not had a lot of exposure, even inside the family, to older individuals and a chance to sort of sensitize themselves to ‘Hey, these people are kind of cool and they're interesting, and it could be intellectually challenging as we live older and older,’ Marciarille says.
“But even in law, you don’t have a lot of people jumping up and down. So maybe it’s unrealistic to expect it in medicine given all the cultural forces and putting aside the financial reward structure.”
Educators like Dedon, Marciarille and Lindholm are working to change perceptions of older adults among their students. They’re beginning to see some small but encouraging signs of success.
“We try to do this in a fashion to assist them in identifying that older adults are a wealth of information, they’re very alive in our society versus the stigma and myth that exist about older adults maybe not being very productive anymore,” Lindholm says.
Dedon notes that his students come not just from UMKC but also from Kansas City University of Medicine and Biosciences, an osteopathic school that focuses on health promotion and disease prevention. About half the geriatric medicine fellows he’s taught over the years have been D.O.s, doctors of osteopathic medicine, and he says some of his very best fellows have been D.O.s.
In fact, caring for older adults doesn’t necessarily require someone to specialize in geriatric medicine, Dedon notes. Primary care physicians are perfectly capable of doing so. They just need the proper training, he says.
“Primary care physicians can take very good care of older adults as long as we give them the education they need,” he says. “My biggest impact is going to be training the students, including the physician assistant students that UMKC has now, med students, residents and fellows, and then continuing to help train community doctors.”
Says Marciarille: “Do they (geriatricians) have to be your primary care, hands-on provider for everything? I’m not sure they have to be.” “The question is,” she says, “does everybody need to have all their primary care from a geriatrician or should it be more like a hub and spoke? Perhaps there should be a geriatrician on consult with an ideally increased number of primary care providers, not all of them M.D.s, who are available.”
Back at Truman, as Dedon continues his examination of his 82-year-old patient, he assures her that another doctor will be checking on her in a day or two. It’s part of “what we do always,” he tells her – a multidisciplinary review.
For now, he wants to know about her emotional state.
“How’s your mood?” he asks her. “Are you a happy person or do you feel sad or depressed?
“Dr. Dedon,” she replies, smiling brightly, “I am happy all the time, morning, noon and night.”
It’s just that kind of doctor-patient interaction, Dedon says, that makes the field so rewarding. And it’s why he’s hopeful that someday soon more practitioners will heed the call to minister to the area’s older population.