Care for the Aged

Dr. Barry Goldlist is director of geriatric medicine at the University of Toronto, and a staff physician in geriatrics and general medicine at Mount Sinai Hospital and the University Health Network. Goldlist spoke with U of T Magazine editor Scott Anderson about the looming shortage of specialists to care for Canada’s elderly population.

How many geriatricians are there in Canada? How many do we need? With 32 million people, Canada has about 200 geriatricians (not all of whom are practising), whereas Sweden, with a population of about nine million, has 500. We would need 1,800 geriatricians in Canada to be as well served, on a per capita basis, as Sweden.

When do people start seeing a geriatrician? Before the age of 75, most people – unless they have early-onset dementia, a disability or a stroke – don’t require a geriatrician. It becomes really important for those over 80.

Why is it important for elderly people to see a geriatrician? Geriatricians have at least five years of training – three years of core medicine and two years or more in geriatric medicine – to specifically address the numerous and complex health issues that elderly people face. Older people often present disease atypically. When they have heart disease, for example, instead of experiencing shortness of breath, they may fall, or become incontinent or confused. It can be difficult to tease out all the factors and determine which ones you can actually do something about. Administering medication to the  elderly is also a problem, since they may have several different prescriptions and are often more sensitive to medications.

How would a greater number of geriatricians benefit Canadian health care? We’ve known for about 25 years that with good geriatric care – in hospitals and on an outpatient basis – elderly people live longer and better. This can add costs to the system: death is a great way to cut down on expenses! But in my view, the improvements in mortality and functional status of the elderly are worth it. Vancouver General Hospital has an acute geriatric unit for people over 75. Patients treated in this unit tend to stay in hospital for a shorter period of time, which reduces costs, and they tend to recover better. This seems to me to be the ultimate win-win scenario: the hospital’s happy because the length of stay is shortened, patients are happier because they can walk out of the hospital.

Why does Canada have so few geriatricians compared to some other countries? In Canada, you can make more money in fields of medicine that, unlike geriatrics, don’t require any additional training. Or, you can enter a field that requires the same amount of training – nephrology, for example – and make more money. Medical residents know the average income of specialists and subspecialists down to the penny. It’s not that they don’t like geriatrics, but they may like another specialty equally and choose that one because it pays better. Also, some residents may not feel the need to make quite that much money, but are burdened with medical school debts of $100,000 or more. Ten years ago student debt loads were nowhere near as high.

What does this mean for the near future? The number of medical students in Canada training to be geriatricians is not enough to replace the practising geriatricians who are expected to retire over the next few years. What’s interesting is that despite the problems we’ve had recruiting medical students to the field, a national physician survey published in the Canadian Medical Association Journal in 2006 reported that allergists and immunologists were the happiest with their profession; geriatricians were second. I’m not surprised. It’s a fascinating field, and you can make a huge difference in people’s lives.