Basin Clinic serves the tiny Western Slope town of Naturita and the surrounding ranching communities with just one full-time staff member, physician assistant Ken Jenks. The part-time staff includes a part-time nurse practitioner and two physicians, who travel from Montrose and Ophir.
Some of Jenks’ older patients take more than a dozen medications and see several specialists, which makes their medical care complicated. Jenks says he would like to consult with a geriatric specialist from time to time, but there are none in the area.
“Thirty percent of our caseload is over age 70,” says Jenks. “I see about two patients a day that could use the services” of a physician specializing in geriatrics, he adds.
A geriatrician is an internal or family medicine physician who completes additional training in care of the elderly. As the national population ages, the shortfall in geriatricians has widened. Colorado is short about 176 geriatricians, according to the American Geriatrics Society.
The scarcity is much more pronounced in Colorado’s rural counties, some of which have seen their populations get older at a quicker rate than the rest of the state, as younger people seek jobs in cities. MedicalQuest, an online database of health care providers and their services, shows that out of the 148 geriatrician practices it lists in Colorado, only five are located outside the Front Range and Grand Junction.
Driving more than a 100 miles to a city to see a geriatrician—or any specialist, for that matter—can be a health risk in itself.
Seventy six-year-old Pat Smith, of Naturita, gave up her license after nearly falling asleep at the wheel a couple of times. Smith has had a number of health issues, including three heart surgeries and a valve replacement. Although she likes the providers at Basin Clinic, she says she wishes she could see a geriatrician who knew more about aging-specific issues.
“There are more older people in the area than younger people,” says Smith. “We have health issues you just don’t see in someone in their 20s.”
Grand Junction internal medicine physician and geriatrics specialist Amy Mohler, MD, knew from a young age that she wanted to take care of the elderly. Her grandparents played a big part in her life, and she has fond memories of running around as a toddler in the nursing home where her mother worked as a nurse.
Physicians like Mohler are rare, however. Most internal and family medicine residents are choosing not to specialize in geriatrics. The extra time required in caring for the elderly, coupled with low reimbursement rates from Medicare and Medicaid, makes specializing in geriatrics unappealing to many.
Mohler is the only geriatrician in Grand Junction, the Western Slope’s largest city. Many of her elderly patients have multiple chronic illnesses such as heart failure, lung disease or degenerative brain disorders. “I turn away people every day,” she says.
Mohler’s practice is structured in such a way that she sees patients only in Grand Valley nursing homes. Her patient visits range from a half-hour to two hours, and sometimes include “difficult conversations” about advance directives. She also spends time talking with patients’ family members.
“There’s not a lot we can fix, so we look at how we manage quality of life,” she says.
Debra Bailey is a family nurse practitioner and director of health sciences at Colorado Mesa University in Grand Junction. Geriatrics is part of the curriculum for the school’s doctorate of nursing program.
The scarcity of geriatricians makes it “difficult to find sites for students to gain exposure with the elderly and their unique issues,” says Bailey. “A lot of new young doctors want young, healthy families in their practice. If a patient ages into a practice, that’s great. If you’re a newcomer to an area, it’s hard to find a primary care physician,” let alone a doctor who specializes in geriatrics.
It can be especially difficult for a physician to treat a new, unfamiliar patient who is on multiple medications and has several different ailments, says Bailey.
Larry Robbins, MD, a geriatrician at Denver Veterans Administration Medical Center, says he gets more referrals locally than from out-of-town physicians, whom he says seldom refer patients to geriatricians.
“Geriatrics is often focused on the oldest of the old, which happens to be growing faster than any other population,” says Robbins. “There will never be enough geriatricians to take care of all the geriatric patients. So the key is for primary care physicians to be well-trained in care of geriatric patients.”
Craig physician Larry Kipe, MD says he used to be board-certified in geriatrics, but decided not to recertify because of the expense.
“I didn’t give up geriatrics—I just gave up certification,” says Kipe. “It’s an expensive endeavor. I still see lots and lots of [geriatric patients].”
Kipe now believes practicing geriatrics in small-town America is impractical. A well-trained internist or family practice doctor can care for most geriatric patients, he says, with occasional consultation with a geriatrician for more complicated cases.
“Family physicians, for the most part, say they are trained in geriatrics and can handle it,” says Christy Whitney, president and CEO of HopeWest Hospice and Palliative Care in Grand Junction. But she notes that, as people live longer, doctors are caring for patients who are much older than in the past.
“A lot of drugs have never been tested on [older] seniors,” says Whitney. “People in their 90s process drugs a lot differently than those in their 60s.”
Whitney speaks from personal experience.
Her elderly mother, who appeared to be dying, was being treated by a cardiologist and family physician when she developed delirium and other serious side effects from a prescribed drug.
Whitney brought her mother to a geriatrician, who took her off the drug. Her mother improved, and lived another five years.
Says Whitney of geriatricians: “We haven’t acknowledged how much we need them.”