Michael Dowling on the healthcare crisis right under our noses

Healthcare leaders are grappling with a daunting healthcare challenge that persists quietly. Day-to-day, it doesn't trigger loud alarms, emergency press conferences, or AI pilots, but addressing it will take immense collective effort.

As of 2022, there were 52 million Americans over the age of 65, a population that grows by 10,000 each day. By 2034, older Americans will outnumber younger ones. An estimated 50% of babies born in 2020 are expected to live beyond 100 years. 

Behind these statistics lies a diverse population: 90-year-olds running marathons and 65-year-olds incapacitated by strokes. Biological age is distinct from numerical age, after all. 

The intensifying demands of an aging population on the U.S. healthcare system represent a challenge of a lifetime, yet one often downplayed or overlooked in the day to day. This aligns with the history of geriatric medicine. The specialty focused on medical care for older adults and the promotion of healthy aging was not widely accepted in the U.S. even in the 1980s. 

"About 25 years ago, if you were in most health systems and you talked about geriatric medicine, most clinicians would tell you there was no such thing," said Michael Dowling, president and CEO of Northwell Health. "There was a denial about the fact that there was geriatric medicine. The idea was that people were older adults that were just getting older."

Mr. Dowling is a co-author of "The Aging Revolution." The book, released in June 2024, highlights the revolutionaries who rejected the status quo in elder care and pioneered new methods to improve aging adults' quality and longevity of life.

Much of the geriatric medicine specialty originates in Northwell's home base: New York City. There, Robert Butler, MD, earned his medical degree in 1953 and not long after began to notice gaps in his education when caring for older adults. Their health needs were more complex, interrelated, and varied, yet they were treated as no different from younger adults. Driven to know more, he joined the National Institute of Mental Health in Washington, D.C., to explore healthy aging, embarking on an irreversible journey. 

Through the 1960s and early 1970s, Dr. Butler grew more impatient with the status quo healthcare treatment of older adults in America. He observed prevailing attitudes of paternalism, infantilism, avoidance or mere caretaking rather than meaningful treatment. 

Dr. Butler made no effort to hide his frustration with the title of his 1975 book, "Why Survive? Being Old in America." In it, he argued that healthcare professionals were not adequately trained to meet the needs of older patients. Their medical conditions were considered uninteresting by teaching institutions and stereotyped as cantankerous and bothersome. The book won the Pulitzer Prize for General Non-Fiction and resonated with other physicians, expanding the circle of healthcare professionals seeking specialization in the care of older patients.

In 1982, Dr. Butler established the Department of Geriatrics and Adult Development at Mount Sinai Medical Center in New York City, creating the first department of its kind in a U.S. medical school. He continued to promote the specialty and the pursuit of knowledge in geriatric medicine, a field in which he had no formal education because it did not exist during his training. Dr. Butler passed away in 2010 at the age of 83.

"He was a powerhouse. It was [Dr. Butler] who basically pushed the issue," said Mr. Dowling. "It doesn't mean it wasn't discussed prior, but he actually took it upon himself to make a difference. That's amazing." 

Mr. Dowling said the book, co-authored with Maria Torroella Carney, MD, chief of geriatric and palliative medicine for Northwell, and author Charles Kenney, aims to raise awareness about the relatively recent development of geriatric medicine. It highlights how a dedicated group of individuals transformed this field from a notable shortcoming into a reality not that long ago. 

The book includes real patient stories and took two years to write, aiming to help readers understand healthcare for older adults vividly and not merely in theory. It covers the rise of palliative medicine in the 1990s, the return of home care and pioneers' work to address the toughest geriatric syndromes, like falls and delirium. 

The questions and shortcomings that Dr. Butler forcefully highlighted in the 1970s and 1980s remain relevant today. Geriatricians provide comprehensive care for adults ages 65 through the end of their life. While this age group consumes more healthcare than any other, there are fewer than 7,300 physicians that are board-certified geriatricians, which is fewer than 1% of all physicians. 

This deficit places greater demands on entire systems, then, to better meet the needs of the aging population. Demand for services will increase, necessitating the evolution and expansion of skill sets, cultural competencies, access points and care settings.

This work makes the practice of geriatric medicine and the advancements made for older patients relevant to far more than the physicians earning certifications in the specialty. Health systems today face questions about what it means to be an age-friendly health system, which requires more than medical care. Age-friendly care is a specific model from the Institute for Healthcare Improvement and The John A. Hartford Foundation that rests on four M's: What Matters Most, Medication, Mentation and Mobility. 

Northwell is one of the largest systems to adopt the framework in all adult acute care settings, primary care ambulatory sites, and post-acute care locations. The effort requires staff training, evidence-based assessment tools and metrics, governance and partnerships with outside institutions. Nationwide, more than 4,000 sites of care have been recognized as age-friendly organizations. 

Mr. Dowling's focus on the topic is a steady one, with more initiatives to come. Aging presents a dual challenge: as people live longer, they place increasing demands on health systems and support infrastructures, compounded by declining birth rates. 

"When the older population is growing by about 10,000 a day, and the population of children is declining, you have this massive imbalance, which is not just a healthcare issue. It's a huge economic issue," Mr. Dowling said. The book does not shy away from the challenge, including a chapter with seven experts addressing the question: How will we as a society deliver and pay for care needed by an aging population where every day 10,000 people turn 65? 

"The Aging Revolution" celebrates the strides made in geriatric medicine and honors the pioneers who led the way, helping our elders avoid unnecessary suffering in the pursuit of longer, fulfilling lives. It also serves as a reminder that the aging of our society demands rigorous problem-solving today and in the years ahead, requiring a spirit of innovation equal to, if not greater than, that which drove its inception.

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