Too many patients, too few doctors

Geriatricians are a dying breed.
They're the specialists who know how to assess and treat the chronic conditions of aging, but they've been neglected and underpaid for so long that medical students are shying away from a specialty that should, by rights, be booming.
Seniors are the health-care system's biggest customer and a disproportionate drain on services. More doctors and nurses trained in geriatric care could save the system untold millions by appropriately treating an aging population – and improve their care.
"An old person can't walk? The standard reaction is: Give them a walker. A geriatrician asks: `Why can't they walk?'" explains Dr. William Dalziel, the renowned head of the Regional Geriatric Program of Eastern Ontario.
"Old people are told they're `frail.' Geriatricians try to `unfrail' them."
Dalziel is a geriatrician (a gerontologist studies aging). There are only 216 in Canada, one-fifth of those needed, and few of them are working with patients full-time. Many focus on research and 43 are close to retirement. There are only six geriatricians in the country under the age of 35.
"We've rarely got more than 10 doctors doing final exams in geriatrics in Canada in one year, and usually much less," says Dr. Barry Goldlist, director of geriatric medicine, University of Toronto, and medical director of the Toronto Rehabilitation Institute.
The shrinking pool of expertise comes at a time when 40 per cent of health-care dollars is spent on seniors, who represent just 13 per cent of the overall population. Studies show that when geriatric services are introduced in a hospital, bed blocking (elders stuck in hospital past their discharge date) goes down by 50 per cent.
When specialists are asked to rank their satisfaction level, geriatricians come out on top. As Dalziel puts it: "Geriatrics appeals to doctors who can embrace complexity – you're dealing with multiple conditions and social factors – and help older people regain their essence. ... My goal is to optimize the person, help them improve so they can feed themselves, instead of being fed." If a geriatrician sees a wobbly older person at risk of falling – which can precipitate a life-ending crisis – he has the expertise to check for common problems such as overmedication and drug side effects. "Keeping seniors from premature institutionalization by proper geriatric assessment and treatment, can save the system millions every year," Dalziel says.
"Most doctors don't know what to do with old people who have multiple conditions. Medical students get, out of 8,000 hours of training, 60 hours in geriatrics. That has to change." In Europe, geriatrics is the second most popular specialty, after cardiology. In the U.K., there are more geriatricians than cardiologists; they're paid the same. The presence of geriatric specialists in U.K. emergency rooms has resulted in significant reorganization and dramatic reductions in wait times.
In Canada, you don't have to be a brain surgeon – or a geriatrician – to alight on obvious fixes: Increase compensation and incentives for geriatric training, which could include a reduction in tuition fees.
Medical school graduates now carry enormous debt burdens and geriatrics in Canada is a low-paying specialty, traditionally earning approximately $200,000. Cardiologists and neurosurgeons earn in the $500,000-plus range. A full-time family physician with a roster of 800 patients earns up to $350,000.
In recent years, most specialties except geriatrics received a pay hike from the provincial government, some by as much as $100,000. This fall, the Ontario government made up for the oversight and raised compensation for geriatricians to $330,000. But it will take time to renew the shrinking pool of expertise. At the University of Toronto, which wants to produce more geriatricians, Goldlist worries there are too few specialists to do the training.
Another fix: accelerate the incorporation of foreign-trained doctors by providing geriatrics training.
Dr. Andrew Padmos, CEO of the Royal College of Physicians and Surgeons, is worried about the deficiencies in health-related human resources planning.
Across the board, we're not producing enough doctors or specialists, and we're too slow in enabling immigrant doctors to work here, he says. "There are 5,000 internationally trained doctors in Ontario who are not working as doctors."
And those who are working are burning out. "I've been a geriatrician for 25 years and I feel like Sisyphus, constantly pushing the rock up a hill," Dalziel says. "We're exhausted. We're so far behind the Europeans." His only hope is that "the baby boomers will wake up. They're assertive. They see what's happening to their parents, and they're realistic enough to realize they don't want to go there."
Dalziel is 57. In a few years, he plans to move to the West Coast and reduce his work load.
And then we'll be down to 215.