LUCKNOW — Two years ago, Alex Peel, now 31, moved back home to practise medicine. She’d gone to school in Thunder Bay and completed her geriatrician residency in London but had always intended to return to Perth County, where she’d grown up on a farm. What she hadn’t counted on was being the only local geriatrician serving Grey, Bruce, Huron, and Perth counties — an area larger than Prince Edward Island and, at 300,000 people, twice as populous.
Geriatricians treat older people, typically those who are frail and struggle with more than one health problem. A subspecialty of internal medicine, geriatrics is similar to pediatrics in that both draw from a body of knowledge about and focus on people at a certain stage of life. Such knowledge is critical, explains Kelly Kay, co-executive director of the Regional Geriatric Programs of Ontario: many medications and treatments are not tested in older populations, and the conventional medical system is structured to deal with one problem at a time — which means that other problems that can contribute to a health crisis for a frail senior, such as a fall, can go undetected.
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In the four counties Peel serves, seniors make up more than a fifth of the population — by 2041, they’re expected to make up more than a third. (In Ontario as a whole, one quarter of the population will be 65 and over by 2041, according to Ministry of Finance projections)
But this area, like many others in Ontario, lacks sufficient geriatricians to serve its aging residents, says Michael Borrie, a geriatrician with St. Joseph’s Health Care London and a professor at Western University.
Borrie was involved in an RGPO initiative that inventoried 20 types of geriatric services and related professionals, including psychiatrists and nurses. The final report, released in March, indicates that the province has only 145 full-time geriatricians — 55 per cent of the 264 geriatricians it needs, Borrie says, per a measure used in British studies that indicates that 1.175 specialists are required for every 10,000 people over age 65. Taking into account such factors as projected population growth, geriatrician retirements, and training capacity in Canada, Borrie projects that the percentage deficit will remain high (the results estimate a deficit of 42 per cent by 2025) and says that the shortage will likely be especially pronounced in rural areas and small communities.
And that shortage compounds the difficulties facing Ontario’s hospitals, experts say, because geriatricians steer the clinical care that can keep frail seniors out of hospitals — and long-term care homes. In doing so, they help relieve the financial burden on the system: according to Kay, it costs on average $1,500 a year (not including such expenses as personal support workers) to deliver geriatric services to a person living in the community versus $50,000 a year and up to provide a long-term care bed or hospital bed.
The Progressive Conservative government, now embarked on a restructuring of the health-care system, has vowed to end hallway medicine, which many blame, at least in part, on the large number of seniors taking up beds while waiting for placements in long-term care.
“To end hallway medicine, you need more specialized geriatric care,” explains Valerie Scarfone, RGPO’s other co-executive director. “What we bring is a specialty that would be able to inform the particulars of how the health-care system needs to be reformed.”
David Jensen, a Ministry of Health and Long-Term Care spokesperson, said in an email to TVO.org that the ministry meets regularly with the RGPO and is relying on the organization to provide guidance on initiatives such as those that identify “investment priorities for people living with dementia and a program that connects primary care doctors to specialized geriatric services.”
“It is true we meet with the capacity planning branch of the ministry, at the staff level, regularly,” Kay told TVO.org via email. “However, as you know, the ministry is quite diverse, and we have only just had an initial conversation with the part of the ministry that is planning for Ontario Health Teams.”
Jensen also said that the number of geriatricians in Ontario increased nearly 20 per cent from 2013 to 2017 and noted that the province’s population aged 75 and older increased only 14 per cent in the same time period. “While the number of geriatricians has indeed increased, this number still falls far short of what is currently needed and will be needed in the future to meet demand,” says Kay.
She says that the organization “can do more to inform the ministry's work in this and other areas, and we welcome the opportunity to be engaged in formal decision-making structures,” noting that the study results will help the organization present its case.
Some steps have already been taken to address the shortage. Borrie says that a pay boost in the mid-2000s stimulated interest in the profession, which remains among the lowest-paid medical specialties in the province. (Ministry of Health and Long-Term Care figures show that geriatricians earned, on average, $277,560 in 2017-18; cardiologists earned, on average, $566,997.)
Medical students have begun to form geriatric interest groups — clubs that help to promote the specialty. “Ten years ago, you find many of geriatric residency spots unfilled; now they are,” says Annie Cheung, an internist resident at Western University. A member of both local and national geriatric interest-group chapters when she was a student at the University of Ottawa, she’s now considering specializing in geriatrics.
Some communities have also been taking action, Borrie adds. A decade ago, Sudbury city council decided to fund a geriatrician to lead clinical services at the North East Specialized Geriatric Centre. Since then, the centre has developed a network of services and introduced satellite clinics in surrounding communities.
But Kay says that, given how severe the deficit is, it’s unlikely that Ontario will be able to get the number of geriatricians it needs. The priority now, along with preserving and increasing training capacity, is improving the mainstream medical community’s knowledge of seniors’ health needs. “This may assist us to optimize our existing geriatric medicine and geriatric psychiatry specialists and reserve their attention for the most complex patients,” she says.
Laura Diachun, an associate professor at Western, has been working with its Schulich School of Medicine to develop components on the treatment of older patients for its 13-week undergraduate foundational program and for courses in such specialized topics as cardiology and hematology. The revised curriculum will be introduced in September. “Even our obstetricians and gynecologists will be doing surgery on older women with incontinence, uterine prolapse, [and] sometimes gynecologic malignancies,” she says. “Save for pediatricians, everyone is going to be working with people over the age of 65.”
Other local efforts are underway to boost care for the elderly. St. Joseph’s Health Care London, for instance, was asked by the former South West Local Health Network to lead the development of a frail-senior strategy to improve access to supports for people living in the region (an eight-county area that extends north to the Bruce Peninsula and south to Lake Erie); Borrie is a member of the committee (although the LHIN is being dissolved, the project is ongoing). And more than 100 primary-care memory clinics made up of family doctors with specialized training now dot the province, improving the accessibility of dementia treatment and facilitating referrals, when necessary, with specialists such as geriatricians, psychiatric geriatricians, and neurologists.
Back in her region, Peel spends much of her working day treating patients at clinics, during home visits, and via the Ontario Telemedicine Network. But she is also trying to raise awareness of senior health issues — an approach that is paying off, albeit slowly. She recalls a recent encounter with a family doctor who’d learned that Gravol (which can cause confusion in older people) had been prescribed to residents at a long-term care facility he’d just assumed responsibility for. “You know, he just approached me right in the parking lot,” she says. Was it safe? he asked. “And I said, ‘No, I don't think that.’” She suggested other medications.
She also sits on committees, such as a four-county geriatric co-operative that involves area medical and mental-health specialists and service providers, so that she can try to persuade others to consider geriatric-friendly approaches to treatment. That’s also why she focuses on building relationships with other health-care providers, such as family doctors, while she travels the region to visit patients.
“I could have been in one place,” she says. “But I feel a responsibility to the people of this area that we [should] try and get as much service to as many people as possible.”