Monday, December 31, 2012

"For life, with all it yields of joy and woe,
                                     And hope and fear, ‑‑believe the aged friend‑‑
                                      Is just a chance o'the prize of learning love”
                                                   Elizabeth Barrett Browning

            I recently had a phone call from a local newspaper wanting to write an article on a success story from our geriatrics clinic. We reached an impasse when we could not agree on what constitutes success. They seemed to want to hear about a healthy person who had been cured. I told them I really don’t take care of anyone like that—and yet I think that we have successes. Those of us who care for the very elderly and infirm tend to think of success as achievement of a good quality of life.   
            One lady who has been a great example of successful aging is Mrs. Leona Davis. She might not seem like the obvious fit for the reporter who wanted someone articulate and photogenic but she thinks she’s aged successfully. The centenarian humped over in a wheelchair with her wig askew, eyes magnified by cataract glasses, and elephantine legs might appear less than model-like. And, it might be hard to believe that she is successful in light of her failing health, her paucity of money, fears of pain and moving to a nursing home as well as absence of family. Yet it seems like her success lies in her strong relationships.  
            After the few family members she had died years ago, Mrs. Davis did not feel sorry for herself—she grew her own surrogate family. This “family” now cares for her with the devotion of the closest of blood relatives. Through their support, she has stayed in her own home alone long beyond when most elderly would be able to do so.
            Mrs. Davis extended herself throughout her life and consequently, developed relationships that span several generations. For instance, she took in the man who now functions as a surrogate grandson about twenty years ago when as a young man, he first emigrated from Cuba. Though he was a stranger, she was happy to help him get started when she allowed him to board free in her upstairs bedroom until he could afford to pay rent. Now a successful businessman with a family of his own, he comes by weekly to visit and help around her apartment.
            The woman who has filled the position of surrogate daughter is a physician for whom Mrs. Davis worked many years ago as a housekeeper. They grew very close and now, despite living a thousand miles apart, they talk weekly and are able to see each other fairly often. This "daughter" financially supports a home health aide to help Mrs. Davis with bathing, cooking and housekeeping.
            Other friends deliver groceries, provide transportation, help with doctor's appointments and just come to talk. Mrs. Davis gave generously from her heart to others throughout the years and now, she is reaping the benefits of the love she has sown and cultivated. Even now, this woman who can barely get around with a walker and can see only with difficulty continues to give to others by tutoring inner city youth in reading, attending an annual summer camp for disadvantaged children and continuing work in her church.
            This giving attitude has left Mrs. Davis vulnerable‑‑and there have been those who have taken advantage of her trusting spirit. But, when she tells the story about the woman who came in to clean her house and stole four‑and‑a‑half pairs of her shoes, she chuckles, "Now, whatever would anyone do with the half pair of shoes?"
            While this remarkable woman certainly has suffered many trials and tribulations in her life, her vibrant stories downplay them. She clearly expresses that all that she has endured is surpassed by the love she experiences from the lives of those that touch hers. This, to me, is "successful aging."

Thursday, December 6, 2012

The first patient I saved

“There are those patients that touch your life, change your attitude, and shape your career. Those are the people that frustrate you when they don't listen, make you laugh when they are obstinate, and make you sad when they are dying. Those are the people that make going to work every day meaningful. Go in peace, friend.”

So said my personal Facebook page recently. As a physician, I meet a lot people every day. Some of them are my patients or their families, some are colleagues, and some I will never see again. And then there are the select few that change my life.

Mrs. Z joined my practice in my very first month of intern year. I met her on the wards in septic shock with an unknown infectious source. After a very relevant morning report one day, I suggested the test that would lead to her diagnosis and cure. I remember being so proud! She was my first central line placement (note I didn’t say successful) and my first patient with 10 problems (certainly not my last). And then she left her prior PCP and joined my clinic… and then followed me to fellowship… and then back to clinic… and then to SNF… and on and on and on. Mind you, she was not an easy patient, but I loved every one of her visits.

And then began the decline.

I saw it, but I didn’t want to. Mrs. Z was a patient with many (and I do mean “many”) active chronic not-so-easy-to-control medical problems. She was a patient with great support from her family and not such great access resources. She was a patient with many diagnoses and way too many “necessary” medications.

She was exactly the kind of patient that led me to a career in Geriatrics. The complexities in her care were astounding. Each problem interacted with the other and each medication led to even more adverse effects. She was the quintessential Geriatrics patient. She taught me to listen instead of focusing only on numbers, that people live (and flourish) independently in a state most physicians consider frail and unsafe, and that family support makes all the difference. But most importantly, she taught me how to be a doctor.

I visited her in the hours preceding her death, and I said “Thank you.”

Wednesday, December 5, 2012

The Assignment...

In Medical Education, everything that we assign the residents is expected to meet some sort of objective and attain a goal. Despite the fact that this blog will not likely meet any pre-prescribed goals or objectives, it will serve a purpose. Its purpose is multifactorial (Surprise, surprise. After all, this is Geriatrics.).

1.      Older adults require more than just care of their medical problems. They are whole people, with social lives and social issues, physical norms and physical illnesses, goals to get better and goals to die in peace. To recognize the complexity of care of the older adult is to appreciate the older adult himself/herself. Write about it.

2.      Internal Medicine residency primarily takes place in the hospital and clinic. Geriatrics, however, takes a resident to skilled nursing, long term care, and yes, even home visits. Residents see the other side of the transition of care, the side to which they often send people and sometimes wonder why the transition failed. This is the chance to recognize ways to improve as they go forward and teach other people not make the same mistakes. Write about it.

3.      Medicine is an art. We go to work, take care of diseases, and go home (to read about more medicine). We forget the art. This is the chance to express yourself. Write about it.

The Assignment: Write about it: your experiences, your surprises, your feelings, your advice, whatever you want. It must relate to the rotation in some way. And it must not contain any PHI. Send it to me by Friday on week 3 of the block for review and posting. (Anyone with an appropriate post, even from outside the residency may post with my approval.)