Between Geriatricians

"Isn't she like 96 years old?"
"OH NO, NO! She's only 89. . . But, she's a very old 89 year old."

Cheers to the PCP!

Specialty expertise others provide is at times invaluable, but I will always have great respect for the kind of (maybe old fashioned) doc who takes care of the whole patient.  I feel that in our era of super specialty medicine, the primary care doctor does not get his or her due.  Here is why the general doc should be respected and applauded . . .

• When you bring up a problem to a PCP, you will rarely hear her say that problem is not under her care.  She won't say, "I am a ____ doctor.  You should ask your primary care doctor."  She will do her best to take care of it.
• She takes care of 10 problems at each visit, often for less reimbursement than your specialist who manages one or two medical issues.
• The PCP takes care of a person, not a heart or a kidney or a bone.  She appreciates that adding a medication for one organ may have impact on another.  
• The PCP knows your values and preferences.  She doesn't practice one-size-fits-all medicine.  She will do her best not to prescribe medications or interventions that don't fit with your values or are impossible.  She knows that since you can't possibly take in a low sodium, low carb, low protein diet without wasting away and so doesn't require this of you, whatever your medical conditions.  

People go into primary care medicine because they care about people.  They place less emphasis on being an expert on one thing and more emphasis on the big picture.  Doing so isn't always easy, but it is rewarding.  For these reasons, I hope that the primary care professions receive the kudos they deserve.

"Happy for today"

http://www.today.com/health/happy-today-carrying-when-alzheimers-strikes-early-2D79797508


This article emphasizes that life goes on even after getting an undesirable diagnosis. Hope this helps people think about the possibility of finding happiness in the moment.

Not a "sexy" specialty?

When I tell lay people I am a geriatrician, I often get a quizzical look and need to explain that I am a doctor for older adults.  When medical students come to work with us, I often find they are not enchanted by our field, which is among the least flashy of them all.

So, imagine my surprise to see this . . .

as a DJ set up for the night at a local restaurant.  A friend actually pointed out to me that he was DJ [Dementia].  I guess we may be hipper than we realize.

Middle of the Road

Too much money to qualify for Medicaid, not enough money to qualify without it.

Looking, searching for a facility, a place to live until you die.

The fancy place says no. You can’t prove your monetary worth, can’t prove you will give them a check every month… until… eternity.

The modest place says no. You will cost them too much. You have too many needs. And you can’t prove you will give them a check every month…

            Until you have no more money to give and the Government

                                                                                                    Takes

                                                                                                               Over.

So you wait. Without a home to go to. Without a place to live. Moving between rooms and buildings, between facilities and hospitals.

            Until you are broke

                                    Or you die

                                                Whichever comes first.

When the best medicine is less medicine

            A majority of our medical education is devoted to the rote memorization of medical facts and than later to the practical application of that knowledge. As an internist this commonly involves the use of various medicines for treatment of ailments. However we must always be vigilant of when stopping medicine may be the best approach.

            I recently established care with a 87 year old woman who had recently moved to the area to be closer to her daughter.  By outward appearance she was a healthy highly functioning individual. After a brief discussion she handed me her medication list, which included 18 different medications and vitamins, many of which are scheduled three times a day or four times a day. After a brief discussion it became apparent the woman was under a tremendous amount of distress from the expense of the medications and difficulty of keeping medications straight. Additionally on review of systems she voiced many complaints that could easily be related to several of her medications.

            Although to any practitioner it was very clear that the patient needed to have some of the medications stopped this discussion can be much harder than expected. After getting push back from the patient and her daughter on stopping any medications we were able to stop only one medication at that visit with the plan to follow-up next month and evaluate if she noticed any changes.

-- Andrew Illif

Discrepancy between percentage of time Residents spend in the hospital training and percentage of time patients spend in the hospital

I have been thinking about the discrepancy between percentage of time Internal Medicine Residents spend in the hospital training and percentage of time our patients spend in the hospital.

My patient with the most hospitalizations this year is Mrs S. She has had 8 hospitalizations adding up to about 1016 hours in the hospital. She is definitely an extreme outlier in terms of frequent hospitalizations and yet she has spent 88% of her time OUT of the hospital.  This is in contrast to the resident who has spent 75% of his training IN the hospital this year (approximately 2304 hours in the hospital and 768 hours training in the outpatient setting). His inpatient learning is intense and he is well equipped to take care of the very sick patients in that setting.  But our patients (with rare exceptions) spend proportionately very little time in the hospital.

Would patients get better care if residents had more exposure to the patients’ out of hospital environments? Here are a couple of examples where knowledge of the patient’s environments would probably decrease unnecessary interventions and cost.

We couldn’t seem to keep Mrs B out of the hospital. She had repeated asthma exacerbations and was hospitalized 11 times in one year. Each time, she was treated appropriately and sent home but the scenario repeated about every month.  When we thoughtfully reviewed her home setting, we discovered her twenty-something year old grandkids would come over and smoke in her house. After having them stop smoking in her house, the next year she was not hospitalized once!

When doing a home assessment, I found Mr G compliant with all of his meds but the only food he had in the kitchen was some neck bones stewing. He said he couldn’t afford more food because his medications were so expensive. We realized that he really didn’t need all of the meds he had been prescribed and others could be switched to less expensive formulations.

Then there was the lady with advanced dementia who during an admission for urosepsis, was deemed to have a high aspiration risk and ended up with a feeding tube. In retrospect, she was always in bed in the hospital and attempts at feeding were made when she was in this suboptimal position. When I visited her at home after the hospitalization, she was up in her chair bright eyed and smiling after finishing a whole breakfast of ooey-gooey pancakes and maple syrup. Instead of making a decision about tube feeding in the hospital while sick, it would have been preferable to have her go back to her own environment to assess.

Have you ever seen a home set up like a nursing home? We just saw one today—the daughter has a bedroom set up PERFECTLY with a bed, supplies, shelving unit and pictures on the wall but free of clutter. As we watched her, we saw that she has trained herself to be as good as any practical nurse I’ve ever seen. The patient has been very stable so she doesn’t qualify for hospice care though we are still giving her palliative/hospice-like care.

While financial incentives push us to teach in the hospital, I but I think residents could be better doctors by exposing them to where the patient spends most of their time and helping them to consider this when they are in the hospital.