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.  

Understanding the disease

How many times have you been at church or social functions and witnessed that “little old lady” that is running the show? From party planning to organizing the Christmas plays to cooking dinners for 30+ people, my grandmother has always been that person.  I often compared her to geriatric patients in my medicine clinic and thought, “how does she do it?”  No one in my very large family was prepared for the day when she suddenly was no longer able to juggle it all.

My grandmother had a very difficult 2013 that all started with her having back surgery.  She had undergone multiple back and other joint surgeries in the past and always seemed to be back on her feet within days (so everyone thought this time would be no different).  Unfortunately, following a very lengthy procedure, my grandmother woke up and really didn’t know anyone.  Her husband of 50 years, her 4 children, the multiple grandchildren, and even great grandchildren that she often babysat, were only intermittently recognized.  At first, I assumed (from 100s of miles away) that she just had hospital delirium.  I received calls almost daily from my very distraught mother asking “what is wrong with her?” and “is she going to get better?”  The longer my grandmother was hospitalized and as the confusion persisted, the less clear those answers became.  The decision was made to take her home after about 2 weeks as we all hoped that she would improve after being back home in her normal environment.  This unfortunately was not the case, she actually declined – screaming all night in pain, became incontinent of stool and urine, and completely exhausted my poor grandfather that was trying to take care of her.  There was no medical background in the family and this situation with my grandmother was not being handled well.  Some blamed my grandmother – they felt that she was “faking”.  Others blamed her pain medications (to the point that they essentially took all of them from her).  Everyone started to fight, cry, and many stopped visiting or communicating.  My grandfather on multiple nights took my grandmother to our local hospital because he did not know what to do with her.  The last night that he took her she was septic and transferred back to the original surgeon who did her surgery.  She was found to an abscess at the level of her new spinal hardware so AGAIN had to go back to surgery.  On one hand, everyone was relieved that maybe the infection was the problem all along and she would now to cured!! On the other hand, here she was going through ANOTHER surgery.  Following the surgery my grandmother’s memory did improve some, but she is certainly nowhere close to the person she was before this all started.  The more I talked with my mother about this case; there were subtle things that had been missed – like the fact that my grandmother had been forgetting places and names long before her initial surgery.  She likely did have some mild cognitive impairment that certainly did not help her in the recovery phase – especially with delirium (and superimposed infection).  My grandmother knows our family members now and is functioning quite well at home, but constantly has to be monitored and requires quite a bit of assistance. 

This story is just one example of the impact that cognitive impairment can have on someone and their family.  It is important to accept the process of aging and understand cognitive decline.  My family has learned a lot this year thanks to my grandmother, and finally has taken the initiative to start learning about cognitive impairment and dementia and how to prepare as things continue to change throughout both of my grandparent’s lives.  Educating family members and patients about what to expect is clearly important in the case above, and something that I have noticed to be emphasized often during my month on geriatrics.  

 -- Lindsey Prochaska

Tweaking the discharge process

During my inpatient months I had not thought much about where the patients end up after their stay.  I know many are going to SNFs and rehabs, but I mostly just imagined a hospital-like setting with a focus on rehab and PT instead of on medical issues.  However, during my first week of geriatrics I realized how vastly wrong my ideas had been.  The care of patients in SNFs seems to be a cross between a hospitalist and a PCP.  You get to see the patients several times, in their normal clothes I might add, over the course of several weeks and are able to build a relationship with them and see (most) improve and able to return home.  You also realize all the things that fall through the cracks on discharge.  The person has diarrhea? It's good to know they don't have C.diff, but it might also be helpful stopping that BID sennakot-s.  Oh, yea lets remove that rectal tube at some point as well.  They were taking Benalopril prior to admit, lets change them to lisinopril b/c it's formulary on discharge.  They are confused, but we don't know what the baseline is, so we cannot justify hospitalization, so lets get them someplace where someone can keep watching them instead of dc'ing home, it's in the best interest of the patient after all.  All of these issues, and so many more, seem kind of oxy-moron after discharge, but while you are getting paged every 5 minutes you lose focus on the fine-tuning.  Being responsible for the discharged patient made me so much more aware of my discharging process, and I wish I had had that experience from the beginning of my residency. 

 -- Kellie Wark

A change in perspective...

I’ve spent years in clinic putting patients on medications to lower cholesterol, lower blood pressure, and improve blood sugars in hopes of extending their life.  I’ve pushed for dozens of colonoscopies, mammograms, and stress tests in hopes to prevent disasters. 

Now, I’m in Geriatrics Clinic taking people off medications and forgoing screening because, well, it’ll probably be something else that kills them first.

I’ve spent the other part of my three years on the General Medicine inpatient teams and ICUs trying to cheat death, halt death, or revive persons from near death. 

Now I’m in a Geriatrics Clinic and it feels like I’m actively planning for someone to die.

…But before you think I’m morbid, let me explain

It all started on my first day in Geriatrics Clinic when I was shown a chart of life expectancies for elderly persons in America.  The concept was simple enough, using a person’s age, gender, and overall health to determine how long they were likely to live.  It took more than an instant to digest that even a rather healthy woman  in her 70s may only have less than 10 years to live on average.  It made me afraid to be in my 70s.

With this information, however, came a new sense of purpose and a new outlook on what I was doing in this clinic.  It was easy to feel as if we weren’t “being aggressive” enough or that we were “being passive” but what it really showed was how at all ages in Medicine, the focus always remains on the patient.  With every decision I’ve made for every patient, every day in the past several years, the common focus is doing the best to provide benefit with the lowest possible risk.  While it initially seemed different than what I had been doing on before, it was the exact same.

So as we sat there, taking medications off her list which were unlikely to provide her any further benefit, it felt liberating.  It was not as I felt earlier, a sign of defeat, but rather a celebration of a life lived to its best.  And as we continued to talk, it was just like my usual clinic, continuing with every visit to make sure that everything we are doing is focused on living a longer and better life.  

What a Wonderful World

“And I think to myself, what a wonderful world”, sang the volunteer to the group of elderly individuals encircling her.  As she continued to sing to the group, I found myself, pen resting on the table, listening and reflecting on the aging population around her.  I was on my second nursing home visit and the geriatrics rotation had taught me two great lessons, the elderly population is complex and the goals of treatment are often different.

Medicine’s complexity has always interested me, the chance to investigate someone’s history, their multitude of symptoms, analyze the collected laboratory data, and formulate a plan. The geriatric population amplifies this process due to their atypical presentations and innumerable psychosocial factors, all in the face of a population with differing goals of care.

As a patient ages, the recommendations for screening and treatment change. The evidence based medicine I have so devotedly learned has been broken on this rotation. Each patient requires an individualized plan based on their physical illness, psychosocial components, and their personal goals. For example, is it truly beneficial to pursue colorectal screening in a patient with a terminal illness? More than once, I have had the opportunity to expand my medical thought process.

This rotation not only taught me to enjoy another multifaceted aspect of medicine, but also provided me with a renewed perspective on life; what are the most significant aspects of life and how to define quality of life.  Watching the volunteer move throughout the crowd, I caught a glimpse of what my future might be like and reflected on what is most important. What a wonderful world it is indeed.

 -- Leanard Riley

Dementia, the bigger picture

My experience in geriatrics has enlightened me on multiple levels. I came to realize the importance of looking at the bigger picture with older patients. It’s not just about focusing on medical problems but also aspects of daily living that may impact overall health. I discovered I can get to know someone very quickly simply by asking questions pertaining to ADLs and IADLs. These are items we as residents often overlook while training in the inpatient setting as we focus quite a bit on the acute problem. I also came to recognize the huge impact dementia has on a patient and their family. In my eye, it is a medical condition that doesn't get enough credit as it truly should. From a physician’s perspective, I realized I should pay more attention to this disease process as it has a multifaceted impact on a patient. In my opinion, unless a person has a family member or friend with dementia, the general public otherwise views this condition as ‘something old people get.’ I hope to educate people that it is much more than that. To look at this from a broader perspective, actor Seth Rogen recently presented a statement to members of congress to encourage funding for research into Alzheimer’s dementia. Despite his witty yet moving speech about his personal experience with a family member suffering from the disease, his presentation was made to a poor showing of congressmen. I have had the opportunity to see various types of dementia in person. I would hope that as time goes on that this condition receives more recognition to the general public's eye about its impact on overall health and ultimately lead to early recognition and appropriate management. Looking back now that I have come to the end of my experience with geriatrics, I do wish I could have had this experience during my intern year. I feel like it would have changed my practice with older patients. Nevertheless, I will definitely carry over what I have learned to the rest of my residency and into my career.

- Arvind Satyanarayan

Ode to the Caregivers, the unsung heros

I was ashamed. After I had been whining about a page last night disrupting my sleep, I met a most amazing woman. I made a house call to see a bedbound lady this morning, Mrs. D. She has been essentially non-responsive with end stage dementia for almost 4 years. And her daughter-in-law, Denise, has been caring for her at home as they say, 24-7. Because Mrs. D is completely paralyzed, she is at high risk of developing bed sores. But for 4 years in Denise’s care, she has not had one bed sore. This could ONLY be achieved because every 2 hours day and night Denise turns Mrs. D, changes her diaper and massages her skin. EVERY 2 hours for the last 4 years. That is 17, 480 times! (Ok, maybe her husband and teenage kids have helped a few times a week, so maybe she has only done it 16,000 times.) That’s just one of the many acts of caregiving she fulfills!

The dedication to perform the physically exhausting and repetitive tasks involved in this level of caregiving is clearly the outward expression of an incredibly deep love and compassion. Denise’s husband is thankful but she doesn’t get any thanks or any response really from the patient or the patient’s other children. Don’t all of us deep down dream about being loved that unconditionally?  WOW!

The crazy thing is, there are hundreds and thousands of caregivers like Denise. They are invisible to most of the world as they are confined to their homes full time or working in institutions like nursing homes that most people try to avoid at all costs. Just as you might not think about the components of your car that keep it functioning, you likely don’t recognize the importance of these caregivers—they may not be very visible but they really are the cogs in the engine of love and life. 

Inspiration from Old Hippocrates

"Cure sometimes, treat often, care always."

I've seen this quote attributed to the Father of Medicine and to Dr. Edward Trudeau (1800s), but I suppose it doesn't matter who said it.  

What matters is that it is a poignant reminder that despite medical advances over years, decades, centuries . . . our calling as physicians remains the same.

There are still so few diseases that we cure.  Perhaps we prescribe antibiotics that get our patients over infections, but much of our time is devoted to corralling chronic diseases, some more successfully than others.

When it comes to geriatrics, in particular, our patients face many conditions that march along becoming more debilitating over time - dementia, heart failure, Parkinson's disease, to name a few. 
Sometimes it makes one feel powerless when patients come to us seeking to "get better."  However, that's when I remember the last two words of the phrase.  Comfort always.  When we put science aside and relate to our patients on a human level, we are always doing them a service.  And perhaps we're doing ourselves as service, as well.   

Hello Sweetie

"Hello sweetie." 

The common phrase that I'd heard since I was a child and the typical greeting that she gave to anyone that came by to see her.  No one noticed that she couldn't remember anyone's names.  It wasn't until we were looking at pictures one day and she said, "Well, that's a good-looking family. Who's that?"  "That's our family, and that's you right there in front," we told her.

As time went by things became more apparent.  The pots left on the stove.  The laundry started but not finished.  The repeated questions a few minutes apart.  I remember shortly before she moved into the long term care facility, I went to visit her with my brother.  She asked me how my grandparents were (her sister and brother-in-law who had passed away about 8 years prior).  I was only 15 or 16 at the time, and I remember the sadness in her eyes as we reminded her that my grandparents had passed.  "Oh yeah, I remember," she said.  A few minutes later, she again asked about my grandparents.  Knowing the distress it caused before, we simply smiled, and said, "they're doing just fine."  "Oh, that's great sweetie," she said.       

Over the next several years, she had a slow and steady decline.  I was working at the hospital when she was admitted nearing her end stages.  She wasn't eating or drinking well, and she was having recurrent episodes of dehydration and infections.  She didn't even know her sisters at the time.  I remember walking into her room as a lab assistant to see her smiling face and hearing, "hello, sweetie", and even though I knew she didn't know me, for a short period of time, she was still the same aunt I had known since childhood.  Thankfully for us, dementia never took that away from her.  

- Adam Merando, MD

Why in the world does my patient need a Geriatrician?

Prior to my rotation on Geriatrics I always asked myself, “why would I send my patient to a Geriatrician when almost all of my patient’s in my Internal Medicine Clinic meet the age criteria as a geriatrics patient?” This answer was quickly answered within one week on this rotation. I soon realized how easily patients can hide their dementia with jokes, laughter, wittiness or even compliments. I have performed mini-mental status exams in the past, but most of the time it was on patient’s that clearly had dementia. When I performed these tests on patients that appeared to have “normal cognition” I was amazed how subtle dementia can be. It was then that I realized that some of these patients are not getting the time and attention they deserve.

One thing that really stuck with me after this rotation is the realization that a full Geriatrics H&P will tell you more about that that patient than three, or even four, Internal Medicine clinic visits will. I had one patient in my regularly scheduled Internal Medicine Clinic that I had seen about three times in the past. His vitals and labs have always looked good compared to any of my other patients. On the surface there were no signs of dementia or even mild cognitive impairment.

However, I decided to ask about ADL’s and IADL’s and I performed a mini-mental status exam on this patient. At that point I realized that this patient had subtle, mild dementia and was requiring a lot more help at home than I had previously expected. This made me reevaluate this patient’s medication list. I asked myself, “do I really need his blood pressure at 120/80 while on HCTZ? What if he becomes orthostatic and he falls and breaks a hip? Does he really need his A1c at 5.7 while on Glipizide and Metformin and risk him having a hypoglycemic event? What is wrong with a goal of 7 or even a little bit higher for his age?”

At that point I decided to really take a look at his medication list and remove those meds that can actually do him more harm in the short run than good in the long run. I was well aware at this point what the life expectancy of a patient is who is 85 years old and I was also aware of the mortality rate of patient with a broken hip after 2 years. I did not want to contribute to this patient’s possible future suffering due to trying to overly correct lab values and vitals. Sometimes less is more.

I have always been trained to have a certain blood pressure and certain A1c and as long as it falls within those ranges then I’m doing my patient a great service. But this is not the case in the elderly population, especially those with dementia which will undoubtedly progress, as the statistics show. So thanks to this rotation I really feel that this new insight and way of thinking will help me as a Hospitalist when I’m caring for my patient and when I’m getting ready to discharge them home or to a facility.

- Michael Gutierrez, MD

California Memories

A small moment can evoke the most vibrant memory

I just left the most amazing conference and I am inspired. Inspired to teach, inspired to learn, inspired to create, and even inspired to live. You might ask how attending a conference with a bunch of academic geriatricians could even come close to evoking this many positive emotions... but it was only the conference. 

This meeting was on the beach in Coronado. It's true, I love the beach. I even love the fact that I have to wear tons of clothing and sunblock to avoid a burn. It's the waves and the serenity. But more than that, this particular beach made me think of my grandparents. 

Pa is still at home in Kansas enjoying his endless and putrid cigars, but he really isn't able to travel easily and certainly not by himself. He and Grandma loved to travel, and travel they did. That is, until her stroke at age 59 left her paralyzed and functionally dependent. 

I imagine that they traveled well prior to that time -- Grandma was the type that got dressed everyday and didn't leave the house without lipstick, carried a fancy purse, and faced the world. And Pa, well he just wanted her to be happy. They would have loved this place together with it never ending beauty, delicious food, and places to sit down and smoke.

I passed a man smoking a pipe on the beach yesterday. Normally, I would have been irritated by the smoke and hurried past. Instead, I stopped directly in the smoke's path and inhaled deeply, loving every morsel of the Cherry Cavendish... or whatever it was. And then I called Pa.

And found out that he and Grandma had been to Coronado... and loved it.