EDITORIAL Gordon Fung, MD, PhD
Medicine for the Phases of Life: The Later Years As I sit down to write this column, humankind has reached a population milestone: 7 billion people now live on planet earth. While this can partially be attributed to the exponential growth in the number of babies being born, we also have to recognize rising life span as a contributing factor. In his 2007 New Yorker article entitled “The Way We Age Now,” Atul Gawande, MD, touches upon the changing demographics in our population:
For most of our hundred-thousand-year existence— all but the past couple of hundred years—the average life span of human beings has been thirty years or less. . . . People died young. Life expectancy improved as we overcame early death—in particular, deaths from childbirth, infection, and traumatic injury. By the 1970s, just four out of every hundred people born in industrialized countries died before the age of thirty. It was an extraordinary achievement, but one that seemed to leave little room for further gain; even eliminating deaths before thirty would not raise overall life expectancy significantly. Efforts shifted, therefore, to reducing deaths during middle and old age, and, in the decades since, the average life span has continued upward. The result has been called the “rectangularization” of survival. Throughout most of human history, a society’s population formed a sort of pyramid: young children represented the largest portion—the base—and each successively older cohort represented a smaller and smaller group. In 1950, children under the age of five were 11 percent of the U.S. population and those over eighty were 1 percent. In 2007, we had as many fifty-year-olds as fiveyear-olds. In thirty years, there will be as many people over eighty as there are under five.
In this month’s issue of San Francisco Medicine, we delve into the last of our “Medicine for the Stages of Life” series by exploring topics specific to the later years of life. First and foremost, a concern for the future of caring for this group is capacity. In their article, several members of the UCSF Geriatrics Division explain how they hope to prepare clinicians for what they refer to as the “Silver Tsunami” coming as the baby boomers age. “While there is an estimated need for 20,000 geriatricians to effectively care for our burgeoning population of older adults, there are about 7,100 board-certified geriatricians in the United States today,” they write. While the basic idea of supply and demand should comwww.sfms.org
fort us here, it seems to not apply. Geriatrics as a specialty is not growing fast enough, for a number of reasons. Income in geriatric medicine and adult primary care is among the lowest in medicine. Additionally, as Gawande explains, caring for older adults is not appealing to many younger docs going into residency. “Mainstream doctors are turned off by geriatrics, and that’s because they do not have the faculties to cope with the Old Crock,” explains Felix Silverstone, a geriatrician. “The Old Crock is deaf. He has poor vision. His memory might be somewhat impaired. With the Old Crock, you have to slow down, because he asks you to repeat what you are saying or asking. And he doesn’t just have a chief complaint—The Old Crock has fifteen.” One certainty is that we will all age and eventually pass away. So will everyone we care about. The quality of care received by an older adult can make a huge difference in how enjoyable the final years are. Good medical care can mean more time living independently, more time being mobile, more time to enjoy the slower pace of the later years of life. “We are, in a way, freaks living well beyond our appointed time,” Gawande says. “So when we study aging, what we are trying to understand is not so much a natural process as an unnatural one.” And we are living well beyond our natural expiration dates because of our own resourcefulness. We in medicine have found so many ways to not only extend life but also to support good quality of life for years beyond what it has been for most of human existence. We now have to draw on our resourcefulness once more to deal with the unintended consequence of our successes: having a large population of older adults in need of specialized care. I hope this issue of the journal will spark thought and conversation among you and your colleagues on how we will adjust our profession to meet this growing need. November 2011 San Francisco Medicine
9