Perspective is everything

In my white coat
Talking to a family
About their options
     for discharge, for goals, for support at home
Defining my expectations
Directing them down a path

In my white coat
Reviewing the med list
Stopping and starting drugs
    without a backward glance
Meeting criteria and guidelines
Documenting reasons for not

In my white coat
Making medical decisions
Based on my understanding
     of the patient's understanding, the family's
Coordinating other providers
Discussing with social services

How different when you shed the white coat

In my grey sweatshirt
Listening to a doctor
About my loved ones options
   for discharge, for goals, for support at home
Hearing their expecations
Disbelieving of the path

In my grey sweatshirt
Hearing the med list
And it's many, many changes
   trying to remember, to understand
Ignoring criteria and guidelines
Stopping the intolerable side effects

In my grey sweatshirt
Making medical decisions
Based on my understanding
   of the provider, of the person, of my family
Coordinating care because
As family and provider both
     I know more than I want to.

PLACEMENT--Arghh!!

I have a love-hate relationship with euphemisms. There are times that it is nice (and even funny) to allude to something without having to say that ugly word, right? It took me a while to accept the euphemisms related to dying. But now I understand that as long as we say "dying" once clearly, euphemisms can soften the blow of a harsh reality.

However, the use of "placement," when referring to a nursing home move disturbs me. It feels cold and in a disingenuous way, makes it seem as though this is happening outside of any one's control and maybe is even a special honor--"Her Placement." Perhaps this language perpetuates the negative perception of nursing homes, too. Of course, moving to a nursing home is emotionally difficult for all involved BUT as hard as it is to face, active supportive language such as -- "It looks like it is time to move your family member to a nursing home" might in fact be more loving and responsible than "she will be placed."

COACH: a window into the home

This part of the curriculum, though short really stood out in my mind as a truly great learning experience. I had started the night before doing a review of my assigned patient’s medications and their discharge summary from their recent hospitalization. The medication list was easy enough to review and jot down, though like many geriatric patients the medication list, including vitamin supplements was extensive. The next portion was the review of the discharge summary. Much like when we saw patients who had been recently admitted the nursing facility the review of the discharge summary allowed us to see what we would want in a summary by evaluating one from the other side. This certainly provided insight into to how to improve my summaries so that they contain everything I would want.

When we got to the apartment complex it was easy to see that the patient, like many of the patients we see regularly in the hospital, was not wealthy. Furthermore, he was housing several other family members in his small apartment complex, which was an added social stressor. My patient, however, despite having multiple health problems, despite having visual impairment, despite having social stressors, had managed to find a means to succeed. His medication list was near identical to the one provided by the hospital, with the few differences being conscious decisions due to identified side effects from his medications. He showed us how he organized his medications and how he managed to remember his upcoming appointments. He was fortunate enough to have a daughter who is a pharmacy technician who appears to be highly medically literate. The patient himself was also quite sharp, which was certainly beneficial. I can imagine without his daughter’s help he would have a much harder time keeping track of his medications, and would likely not be doing as well clinically. The same would likely be true if his cognition was not as good as it was.

Because he was doing so well clinically we were able to pare down on some of his medications, for which he was very grateful. Despite this he still had a toolbox full of pill bottles to take on a daily basis. We were fortunate in seeing a highly motivated patient who despite having a tough home situation was able to overcome his adversities. However this one patient might be more of an exception than a rule. How many patients keep coming back to the hospital because they can’t understand how to manage 20+ medications? Or lack the social support structure needed to take care of themselves.  Ultimately, what made this visit memorable was not just the visit itself, but the multiple permutations of possible visits and the multiple challenges each possible permutation might present. 

Joys of Geriatrics

Geriatrics is a crucial rotation to have in residency training.  I’m glad that residents can start taking it earlier than their third year now.  The rotation and the attending physicians involved really make you step back and look at the whole picture.  So often I think that we, as residents, get caught up in the minute details and linguistic web of describing someone’s coronary anatomy, or quantifying how much air they can blow out in one second (which is still important); that we lose sight of looking at the patient and their progression through a lifetime.  Geriatricians are emphatic about looking at the whole patient, which I think is a quality any physician should aspire to possess.

                Not only is this broad view incorporated; but also paying attention to the subtlety of a patient’s presentation.  The tempo of their speech.  The way that they walk before sitting down.  Small changes in behavior patterns such as beginning to eat less.  Presentation of common diseases is often subtle, and not textbook when dealing with elderly patients.  A good example of this is depression; which is why it is so important to screen in this population.  Physicians have to be thorough in this population, otherwise treatable disorders can get missed.

                Overall, I enjoyed my time spent on the Geriatrics rotation.  Not only for the reasons and lessons above, but I believe that it made me a more thorough and caring resident.  There was an element of continuity in the nursing homes that I enjoyed.  Regrettably, I will not be able to see how those patient’s do over the next coming months.  For a rotation that I thought I was not going to enjoy, I was certainly both impressed and humbled; not only by the physicians that I worked with, but also by the patients that allowed me to participate in their care.

-- Mitch Tener

Shocking news!

I had a medical school gerontology professor who would always open his talks in a dramatic, hushed tone saying, "I have a secret to tell you . . . none of us are going to get out of here [this life] alive."  It is an undeniable fact.  The billions of humans who came before us all have had the same fate.  What's surprising then, I suppose, is that the assertion sounds so bold and almost startles us.

The comment could compel you to:
A) Live in the fear of the unknown after our earthly bodies fail us, or
B) Make the life you have as lively as possible

I choose B, and I like to think that as geriatricians we choose B for our patients, as well, by championing for quality of life instead of single-mindedly waging war on death.  With that in mind, my professor's declaration invokes not alarm, but a smile whenever it comes to mind.