Missing M.D.s

By Andrew Goldstein

Stephen Bzdok began experiencing seizures at age 65, and doctor after doctor was unable to discover the cause. A Las Vegas lounge singer for more than 20 years, Bzdok nearly became homebound. The internists and neurologists he saw never took the time--and didn't have the expertise--to figure out what was wrong. Then an especially fierce seizure put Bzdok in a coma for four months. His family, assuming the worst, sold most of his possessions. One day, miraculously, Bzdok woke up. This time he consulted a geriatrician--a doctor with special training in care for the elderly--who soon discovered the problem: a heart murmur. Bzdok had a pacemaker implanted, and has been seizure free ever since. The fun-loving sexagenarian says he feels as if he were 50 again. He lives on his own, walks half a mile a day and spends weekends on a speedboat.

If only the rest of the nation's seniors were as lucky. When politicians and journalists talk about problems in elder care, they usually point to horrific abuse in nursing homes or to retirees who are forced to skip meals to pay for prescription drugs. But the most serious crisis in elder care has been largely ignored: not enough doctors who know how to diagnose and treat aging's special ailments. Out of 650,000 physicians in the U.S. today, just 9,000 are certified in geriatric medicine. And that number is shrinking, as many quit the poorly paid field or retire. Only 3 out of 144 U.S. medical schools have a full department in geriatrics (all have a department in pediatrics), and fewer than 3% of medical students take even one course in geriatrics, according to the International Longevity Center. During the next 30 years, more than 70 million baby boomers will reach age 65. Who will care for them?

Medicine for the elderly is a different science from medicine for the young or the middle-aged. Seniors face a range of age-related ailments--dementia, Alzheimer's, arthritis--and typically swallow more than four medications a day. A doctor's attention to how drugs interact can mean the difference between saving a life and taking one. Many geriatricians say they devote much of their efforts to sorting out the complications caused by their patients' previous doctors. Each year 17% of elderly Americans are hospitalized after experiencing a dangerous drug interaction or taking incorrect dosages. The American Medical Association says nearly 7 million seniors a year are routinely prescribed drugs that are too risky for them.

Mary Richert, 79, of Jennings, La., had been living on her own, taking trips as far away as Alaska, until she began suffering from memory and balance problems. She stopped driving and traveling and became depressed. At the urging of her children, she spent 18 months trying to find a doctor who could help her. But the message from the series of internists, urologists, neuropsychologists and neurologists she saw was always the same: "Mama's problems are because Mama's getting older."

That wasn't the reason. Two years ago, Richert went to see Charles Cefalu, one of the top geriatric specialists in the U.S. "He was different from any doctor I had been to," says Richert. "He took his time." Cefalu's thorough examination helped him figure out the cause of Richert's seeming dementia: her brain--like that of a child born with "water on the brain"--had stopped draining cerebral fluid. Cefalu sent Richert to a neurosurgeon, who placed a shunt inside her brain to act as a drain. Her health improved dramatically. Today she gardens, travels and--to the consternation of her children--is driving again.

It's an inspirational tale, yet what saved Richert is what keeps doctors away from geriatrics: it takes time to diagnose elders' problems. A physician is reimbursed by insurers for a typical office visit of 15 or 20 minutes. But a geriatrician needs on average at least an hour for an initial assessment. While a general internist can see 2,000 to 3,000 patients a year, a geriatrician sees fewer than 500 patients, making for a smaller income. Says Joseph Ouslander, head of Emory University's geriatric-medicine program: "I can go into my clinic and spend an hour with a very complicated 90-year-old patient, identify her 10 medical problems, sort out her dozen medications, talk to her children. And I get the same reimbursement as the dermatologist who spends 30 seconds shaving off a mole."

A geriatrician's income is almost entirely dependent on the amount that Medicare pays for each patient, in effect leaving the doctor's salary up to the Federal Government. And this year Congress has cut Medicare reimbursements 5.4%. Louisiana Senator John Breaux, who chairs the Senate Aging Committee, is one of the few members of Congress to call attention to the shortages in elder care, most recently at a hearing last February. Yet Breaux, a fiscal conservative, told TIME he won't consider raising Medicare reimbursement rates. "That's not in the cards right now," he says. Instead, he proposes forgiving student loans to doctors who go into geriatric medicine.

A handful of medical schools have begun to boost their geriatric programs, despite the lack of student demand. (One medical resident said he never took a class in geriatrics because "old people are gross.") Cefalu started an expansive program at Louisiana State University that he hopes will act as a model for other schools. But when Greg Sachs, chief of geriatrics at the University of Chicago, launched a geriatrics fellowship in 1986, only a few young doctors entered the two-year program, in fits and starts, and interest dried up altogether in the mid-'90s. This year Sachs has just a single fellow.

When the legions of baby boomers begin to retire, many will need the kind of geriatricians who have the skills to save people like Bzdok and Richert. Jennifer Moore, 30, hopes to be such a doctor. Inspired to go into geriatrics by watching her grandmother take care of her grandfather after he suffered several strokes, Moore followed med school with a two-year fellowship in geriatrics. But now she's having trouble finding a satisfying job. "How can I provide good care in the manner in which I was trained," she asks, "when all I get is 10 minutes with each patient?" Unwilling to compromise her standards, Moore is looking to teach geriatric medicine instead. Now the question is whether she can find some students. --With reporting by Alice Jackson Baughn/Louisiana, Paul Cuadros/Durham, Deborah Fowler/Houston, Kathie Klarreich/Miami, Greg Land/Atlanta, Jeanne McDowell/Los Angeles and Maggie Sieger/Chicago

With reporting by Alice Jackson Baughn/Louisiana, Paul Cuadros/Durham, Deborah Fowler/Houston, Kathie Klarreich/Miami, Greg Land/Atlanta, Jeanne McDowell/Los Angeles and Maggie Sieger/Chicago