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For care of elderly, not enough specialists

Dr. James Steg visits with Martha Cruise, 78, of Seminole at Palm Garden of Pinellas, a nursing and rehabilitation center. Cruise was admitted to Palm Gardens in mid November with chronic lung disease.


Dr. James Steg visits with Martha Cruise, 78, of Seminole at Palm Garden of Pinellas, a nursing and rehabilitation center. Cruise was admitted to Palm Gardens in mid November with chronic lung disease.


Dr. James Steg stopped by to check on one of his nursing home patients and found himself chatting about her brush with death.

Martha Cruise, 78, had recovered so much that she was in a physical therapy class, doing stretches in her wheelchair, when Steg found her.

"They thought I was dying," Cruise told Steg, as they talked about her recent illness. "Now I'm going home. With your help."

Steg listened to her lungs, making sure her breathing troubles were under control, and asked about her plans to go home to hospice care.

Steg would like to keep seeing patients like Cruise, to make sure she does all right. But he can't. Too many patients — all elderly, and most with multiple health problems — demand his attention. Steg is one of only a few thousand doctors in the United States who specialize in treating the elderly.

Some of these doctors, like Steg, spend most of their time in nursing facilities. Others have more traditional private practices or work mostly at hospitals.

Wherever they work, they have one thing in common. These doctors are in short supply. In some places, elderly patients have an easier time seeing a cardiologist or a neurosurgeon than finding a new primary care doctor.

"Right now, our practice has a three- to six-month wait to get a new patient into the practice," said Dr. John Murphy of Rhode Island, president of the American Geriatrics Society.

And the shortage is expected to grow.

As America ages, the demand for doctors like Steg is predicted to explode. Between 2005 and 2030, the number of Americans who are 65 or older will nearly double. By that time, the United States will need about 36,000 doctors who specialize in caring for the elderly, according to a report released this year by the Institute of Medicine.

But the country now has only about 7,100 doctors who specialize in geriatrics. Most studies project that figure will increase by 10 percent at most, and could fall. As medical students flock to lucrative specialties, such as dermatology and orthopedics, fewer are going into primary care. Fewer still decide to get extra training in geriatrics.

"Older patients have unique needs," said Lori Parham, state director for AARP Florida. "We see a well-trained geriatric work force as vital to seeing that older Americans get the care they need."

AARP already is hearing from members about difficulties finding doctors, Parham said. The group helped sponsor this year's Institute of Medicine report and has endorsed its suggestions for boosting the work force.

Largo resident Etta Metcalf, 89, said she likes knowing that her doctor specializes in older patients. Steg treats not only her, but also her two sisters, ages 84 and 90.

"He does such a wonderful job," she said. "He seems to enjoy it, and to have three of us is quite something."

Doctors are expected to be able to treat patients of all ages. But doctors who treat the elderly say they're more prepared to properly treat their medical needs. With many older people suffering from multiple medical problems, overmedication is a constant concern.

For example, a few weeks ago, Steg saw a new patient. The 96-year-old woman had recently fallen and broken a hip. She had been given a feeding tube through her stomach because she wasn't alert enough to eat.

Steg looked at her chart and changed the pain medicine for her hip to a nonsedating one. She was soon able to eat and talk again, and the tube was removed.

"When you start talking about the very frail older patients, who are on eight or 12 medications, your typical internist or family doctor doesn't have the ability or confidence to say, 'We're going to stop this drug. That one's not indicated.' That's what geriatricians bring to the fore," Murphy said.

Geriatricians also are more practiced at spotting medical problems that others may accept as part of the natural decline of aging, said Murphy, who is also a professor at Brown University's Alpert Medical School.

"Often somebody accepts that a person's just a little less steady on their feet," Murphy said. "But it's not because they're older. It's because they're deconditioned, or they have a podiatric condition."

Older people also may have different symptoms, said Dr. Joseph Stubbs, president-elect of the American College of Physicians. For example, signs of pneumonia can be as subtle as losing appetite and alertness.

Without more geriatricians, these doctors fear that more elderly patients will wind up in emergency rooms because they delay care. Or they'll get treated in hospitals, go home, and suffer complications because they don't have good care in the community.

Many medical schools offer special training in geriatric care, including the University of Florida and the University of South Florida.

But right now, geriatrics isn't as attractive to medical students. In 2006-2007, only 54 percent of the available slots for graduate training in geriatrics were filled. Students, who often finish medical school with six-figure debt, know they can make more money in other specialties.

"In medicine, we don't get paid to think," Steg said. "We get paid to do."

In other words, doctors make more by performing surgeries and procedures than by sitting down with a patient to figure out how to diagnose and treat a complex set of medical problems.

In 2005, the average geriatrician was paid $162,977, compared with $174,664 for internists and $216,199 for neurologists.

Murphy and Stubbs hope that health care reform will help change that equation. They're looking for other changes as well, such as forgiving loans for medical students who go into geriatric care and improving training in geriatrics for all doctors.

Steg hopes that medical students will realize there's an intangible benefit as well.

"Older people are interesting to talk to," he said. "I learn from them."

Lisa Greene can be reached at or (813)226-3322.

For care of elderly, not enough specialists 12/07/08 [Last modified: Monday, December 15, 2008 2:35pm]
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